Delaware Journal of
Volume 11 | Issue 5
December 2025
Public Health The official publication of the Delaware Academy of Medicine and Public Health
Advances in Maternal and Child Health
www.delamed.org
Delaware Academy of Medicine & Public Health – OFFICERS – Stephen C. Eppes, M.D. President Jeffrey M. Cole, D.D.S., M.B.A. President Elect Ann Painter, M.S.N., R.N. Treasurer Megan L. Werner, M.D., M.P.H. Secretary Lynn C. Jones, L.F.A.C.H.E. Immediate Past President Katherine Smith, M.D., M.P.H. Executive Director – DIRECTORS – David M. Bercaw, M.D. Peggy M. Geisler, M.A. Jennifer A. Horney, Ph.D., M.P.H., C.P.H. Eric T. Johnson, M.D. Erin M. Kavanaugh, M.D. Joseph Kelly, D.D.S. Omar A. Khan, M.D., M.H.S. Daniel J. Meara, M.D., D.M.D. Jonathan M. Miller, M.D. John P. Piper, M.D. S. John Swanson, M.D. Charmaine Wright, M.D., M.S.H.P. – EMERITUS – Barry S. Kayne, D.D.S. Joseph F. Kestner, Jr., M.D. Brian W. Little, MD, Ph.D. – ADVISORY COUNCIL – Omar Khan, M.D., M.H.S. Peggy M. Geisler, M.A. Co-Chairs Katherine Smith, M.D., M.P.H. Executive Director – COUNCIL MEMBERS – Alfred Bacon, M.D. Gerard Gallucci, M.D., M.S.H. Allison Karpyn, Ph.D. Erin K. Knight, Ph.D., M.P.H. Laura Lessard, Ph.D. Melissa K. Melby, Ph.D. Joyce Robert, M.D. William Swiatek, M.A., A.I.C.P.
Delaware Journal of Public Health Katherine Smith, M.D., M.P.H. Publisher Omar Khan, M.D., M.H.S. Editor-in-Chief Audrey A. Merriam, M.D. Guest Editor Suzanne Fields Image Director
ISSN 2639-6378
Delaware Journal of
December 2025
Public Health Volume 11 | Issue 5
The official publication of the Delaware Academy of Medicine and Public Health
3 | In This Issue: Advances in Maternal and Child Health
66 | The Role of Health Education in Maternal and Infant Health
Omar A. Khan, M.D., M.H.S.; Katherine Smith, M.D., M.P.H.
Adrienne Palmer, M.S., C.L.S.
4 | A Word from the Guest Editor Audrey A. Merriam, M.D.
6 | A Ten-Year Retrospective Look at Maternal Deaths in Delaware Through Maternal Mortality Review Meena Ramakrishnan, M.D., M.P.H.; Elisabeth Z. Klein, D.N.P., M.S.N., B.S.N., R.N.C.-O.B., R.N.C.-L.R.N.
18 | Historical Claims Literature Review Paper: Black Maternal Health
68 | Global Mapping of Evidence on Vaccination Related Education Through School Based Curriculum: A Systematic Scoping Review Bhupender Singh Khanuja; Palak Badhwar; Kapil Singh; Shipra Verma; Anjori Agrawal; Ashwani Verma
78 | Hepatitis B Birth Dose
Jasmine R. Hilliard, L.S.C.W.
Stephen C. Eppes, M.D.; Katherine Smith, M.D., M.P.H.
24 | Obstetric Triage as a Gateway to Social Care: Social Needs, Disparities, and Implications for Advancing Equity
80 | Progress Made, But the Work Isn’t Done: Delaware’s Path on Maternal and Infant Health
Alicia L. Salvatore, Dr.P.H., M.P.H.; Michelle Axe, M.S., C.H.E.S.; Mathew K. Hoffman, M.D., M.P.H., F.A.C.O.G.
36 | Rethinking Prenatal and Postpartum Exercise Julia Olsen, Ph.D.
42 | Global Health Matters Newsletter November/December 2025 62 | Bridging the Gaps between Aspirin Guidelines|and Pregnancy Outcomes
Melissa C. Minor-Brown, M.A.; Marie Pinkney, L.C.S.W.
82 | Children’s Health: 2025 and Beyond Stephen C. Eppes, M.D.
83 | Index of Advertisers 84 | Resources 86 | Delaware Journal of Public Health Submission Guidelines
Matthew K. Hoffman, M.D., M.P.H.
The Delaware Journal of Public Health (DJPH), first published in 2015, is the official journal of the Delaware Academy of Medicine and Public Health (Academy). Submissions: Contributions of original unpublished research, social science analysis, scholarly essays, critical commentaries, departments, and letters to the editor are welcome. Questions? Contact managingeditor@djph.org . Advertising: Please contact ksmith@delamed.org for other advertising opportunities. Ask about special exhibit packages and sponsorships. Acceptance of advertising by the Journal does not imply endorsement of products. Copyright © 2025 by the Delaware Academy of Medicine and Public Health. Opinions expressed by authors of articles summarized, quoted, or published in full within the DJPH represent only the opinions of those authors and do not necessarily reflect the official policy of the Academy, the DJPH, or the institution with which the authors are affiliated. Any report, article, or paper prepared by employees of the U.S. government as part of their official duties is, under Copyright Act, a “work of United States Government” for which copyright protection under Title 17 of the U.S. Code is not available. However, the journal format is copyrighted and pages are not be photocopied, except in limited quantities, or posted online, without permission of the Academy/DPHA. Copying done for other than personal or internal reference use-such as copying for general distribution, for advertising or promotional purposes, for creating new collective works, or for resale- without the expressed permission of the Academy/DPHA is prohibited. Requests for special permission should be sent to managingeditor@djph.org .
IN T H IS ISSU E Advances in Maternal and Child Health Maternal and infant mortality are high in the United States due to various intersecting public health issues like widespread chronic disease, systemic racism leading to disparities (especially for Black women and babies), inconsistent healthcare access, lack of paid maternity leave, and fragmented postpartum care. According to the World Health Organization, in 2023, over 700 women died per day from preventable causes related to pregnancy and childbirth. That comes out to about 260,000 women per year, and over 90% of these occurred in low- and lower-middle income countries. Most could have been prevented.1 This number had been declining worldwide since 2000, yet the United States was one of only seven countries to report that maternal mortality had increased.2 While the causes are several, it is noteworthy that taken in aggregate, cardiovascular causes (including stroke, high blood pressure, and blood clots) account for nearly half the causes of maternal death, suggesting that improved control of pre-pregnancy cardiovascular risk factors is key for maternal health during pregnancy. The Commonwealth Fund’s 2025 Scorecard on State Health System Performance revealed the states with the highest maternal mortality rates (figure 1) had some of the worst overall health system performance. Delaware ranks smack in the middle of health system performance, at number 25, and showed an infant mortality rate of 7.5 per 1,000 live births in 2022 (up from 5.9 in 2018).3 Figure 1. United States Maternal Mortality Rates by State, 2025
In the last several years, greater attention has been paid to global causes and solutions, many from right here in Delaware, some published in this Journal.4–6 The causes of maternal death globally (such as postpartum hemorrhage and sepsis) are not so different from those in parts of the US, and are certainly amenable to system-wide solutions focusing on data, disparities, access to care, and addressing the underlying determinants of maternal health.6 In this issue of the Delaware Journal of Public Health, we welcome guest editor Audrey Merriam, MD, MS, a physician with the Delaware Center for Maternal and Fetal Medicine at ChristianaCare and program director for the Ob/Gyn Residency Program. Dr. Merriam has curated a comprehensive and informative issue highlighting maternal and child health in Delaware, and we thank her for her hard work. As always, we look forward to your comments!
REFERENCES 1. World Health Organization. (2025). Maternal mortality. Retrieved from https:// www.who.int/news-room/fact-sheets/detail/maternal-mortality 2. World Health Organization. (2023). Trends in maternal mortality 2000 to 2020: Estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. Retrieved from https://www.who.int/publications/i/item/9789240068759 3. The Commonwealth Fund. (2025). 2025 Scorecard on state health system performance. Retrieved from https://www.commonwealthfund.org/publications/ scorecard/2025/jun/2025-scorecard-state-health-system-performance 4. Derman, R. J., Goudar, S. S., Jaeger, F. J., & Khan, O. (2018, July 25). Global maternal and child health: A research partnership’s approach for addressing challenges and reducing health disparities in developing countries. Delaware Journal of Public Health, 4(4), 4–12. https://doi.org/10.32481/djph.2018.07.002 PubMed 5. Khan, O. A., Derman, R., & Sloan, N. L. (2013, July 29). Advancing maternal survival in the global context: Are our strategies working? BMC Public Health, 13, 689. https://doi.org/10.1186/1471-2458-13-689 PubMed 6. Washio, Y., Khan, O., & Rivera-Gutiérrez, R., & the FAAFP;2. (2018, May 10). Maternal health disparities among Puerto Ricans. Delaware Journal of Public Health, 4(3), 58–59. https://doi.org/10.32481/djph.2018.05.011 PubMed
Figure reproduced from CDC data as presented in Reference 3
Omar A. Khan, M.D., M.H.S. Editor-in-Chief, Delaware Journal of Public Health
Doi: 10.32481/djph.2025.12.01
Katherine Smith, M.D., M.P.H. Publisher, Delaware Journal of Public Health
3
Guest Editor
From the Guest Editor
Audrey A. Merriam, M.D. Delaware Center for Maternal and Fetal Medicine, ChristianaCare
This issue of the Delaware Journal of Public Health focuses on issues affecting the maternal-child dyad. Efforts to improve both health care and public health policy for children and birthing persons are now being rolled back and devalued at a national level. This makes policy and strategies at the state level even more important, so we can continue to improve health outcomes on a large scale for these vulnerable populations. This issue opens with a summary of the findings and work of the Delaware Maternal Mortality Review Committee over the past 10 years. This article aggregates data to provide a summary of trends in pregnancy related mortality and examining the intersection of substance use disorder and co-occurring mental health disorders, which are the leading causes of maternal death in the state. The work of this committee has provided important policy recommendations to continue to protect birthing persons in the state. The next article by Hilliard describes the long-standing issues with racism in medicine, particularly in women’s health care. The suggestions for improvement at the end of this paper have been implemented by various health care facilities, and may be a contributing factor to the lower percentage of pregnancy associated death experiences by Black, non-Hispanic individuals between 2020-2024 compared to 2015-2019 in Delaware.
The articles by Salvatore, et al, Palmer, and Olsen highlight important interventions in both social and physical health contexts that could serve to improve maternal health and maternal health outcomes for individuals in Delaware. The commentary by Dr. Hoffman on aspirin use in pregnancy reviews how this simple medication could improve maternal and neonatal outcomes through prevention of preeclampsia and preterm birth. Finally, the last article provides important information on another option for increasing education in this era of vaccine hesitancy and misinformation from a global perspective. Although, this systematic review includes articles from multiple countries, there are important take aways that may be able to be implanted in Delaware, especially given the large number of private schools. I hope this issue highlights important issues facing maternal and child health, both nationally and in the State of Delaware. At this time where national policy is increasingly rolling back protections for these populations, state policy and local health care measures are becoming exceedingly important to ensure we continue to move the needle on outcomes for children and birthing persons.
Doi: 10.32481/djph.2025.12.02
Correction In the November 2025 issue of the DJPH (Nutrition and Malnutrition as a Determinant of Health), two articles were funded by “Healthy Eating Research, a national program of the Robert Wood Johnson Foundation:” • Appel, et al. Mitigating Food Insecurity-Related Stigma: A Review of Intervention Strategies • Halverson, et al. Structural-Level Stigma Within Emergency Food Assistance Programs: Perspectives from Delaware and Pennsylvania The funding agency has updated their required acknowledgement language: These articles are supported by Healthy Eating Research.
4 Delaware Journal of Public Health - December 2025
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5
A Ten-Year Retrospective Look at Maternal Deaths in Delaware Through Maternal Mortality Review Meena Ramakrishnan, M.D., M.P.H. Elisabeth Z. Klein, D.N.P., M.S.N., B.S.N., R.N.C.-O.B., R.N.C.-L.R.N.
ABSTRACT Objective: This study describes the ten-year evolution of Delaware’s Maternal Mortality Review (MMR) and key findings over two five-year periods of review: 2015-2019 and 2020-2024. Methods: This retrospective study describes the causes of death, key characteristics and priority recommendations documented in pregnancy associated deaths reviewed by the MMR Committee between 2015 and 2024. A pregnancy associated death is defined as the death of a Delaware resident while pregnant, or up to one year after the end of pregnancy, from any cause. Results: In the ten-year time period from 2015 to 2024, 75 cases were fully reviewed by the Delaware MMR Committee. Due to better case identification processes with the addition of vital statistics linkage in 2017, 58% more cases were identified and brought before the Committee in 2020-2024 compared to 2015-2019. Thirty-four percent and 20% of cases were determined to be pregnancy related in 2015-2019 and 2020-2024, respectively. A pregnancy related case is one in which the person’s death is causally linked in some way to her being pregnant. Most pregnancy related cases occurred in the early postpartum period, within 42 days of delivery. In contrast, most pregnancy associated but not related cases occurred in the late postpartum period, months after delivery. Overdose was the single most common cause of death reviewed by the MMR Committee, most often representing the intersection of mental health conditions and substance use disorder. Conclusion: Recommendations put forth by the MMR Committee focus on implementing evidence-based standards and coordinated care across physical health, behavioral health and social domains. Policy Implications: MMR is a key public health program that provides the most in-depth, comprehensive source of information on the drivers of maternal mortality in the state and its associated risk factors.
INTRODUCTION Maternal mortality is an important indicator of the health of young women in a population and the effectiveness of systems of care to ensure their well-being during and after pregnancy. In the U.S., a long-standing indicator of maternal mortality is the pregnancy related mortality ratio (PRMR) reported by the Center for Disease Control and Prevention’s (CDC) Pregnancy Mortality Surveillance System (PMSS). The U.S. PRMR has been increasing by this report since the mid 1980’s.1 The PMSS considers deaths that occur during and up to one year after the end of pregnancy. Medical epidemiologists make the determination of pregnancy relation—whether or not a death is causally linked to pregnancy— based on information available on the death certificate and any linked fetal and live birth certificates. However, the determination of pregnancy relation is limited by the accuracy of the vital statistics information available. Over the last fifteen years there have been growing efforts in the U.S. to systematically conduct in-depth reviews of maternal deaths to more carefully determine pregnancy as a causal link in the chain of events leading to death, other contributing factors in the death, and system level opportunities for prevention. Pregnancy and postpartum offers a unique window to engage more frequently with women about their health and, in so doing, manage any chronic medical issues, provide anticipatory guidance on pregnancy and potential complications, screen for healthrelated social needs and offer referrals for additional supports. 6 Delaware Journal of Public Health - December 2025
The rising PRMR is a harbinger of growing gaps between women’s needs and the ability of current systems of care to address them. The CDC has been a foundational organization to convene many jurisdictions and create a collaborative approach to systematically review maternal deaths. These efforts have included the creation of standardized databases and tools to define, review and deliberate maternal deaths. In 2019, the CDC also launched the Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE-MM) grant. Delaware was among the first states to be awarded this grant to enhance its Maternal Mortality Review (MMR) program. However, Delaware’s efforts to conduct MMR precede the ERASE-MM grant. The Delaware General Assembly changed the statute of the Child Death Review Commission (CDRC) in 2011 to add the functions of MMR to the CDRC’s existing programs of child, fetal and infant death review.2 In that year, the CDRC instituted an MMR program and separate panel, under its direction, for reviewing select maternal deaths occurring after July 1, 2008. The statutory purview of Delaware’s MMR is to review the deaths of Delaware residents occurring while pregnant or up to one year after the end of pregnancy, irrespective of cause, and in keeping with the highest national standards. As the oversight body for the MMR, the CDRC’s statute was again changed in 2022 to update the Commission’s name to the Maternal and Child Death Review Commission (MCDRC), recognizing the complete breadth of its work.2 Doi: 10.32481/djph.2025.12.03
Delaware statute and CDC standards of review guide much of the MMR’s work and enable Delaware to contribute meaningfully to national evidence on the causes and drivers of maternal deaths in the U.S. The Delaware MMR Committee is a diverse, multidisciplinary team including statewide representation in the fields of obstetrics and gynecology, maternal fetal medicine, internal medicine and critical care, nursing, social work, behavioral health, public health and community health. The MMR Committee strives to include a balance of clinical and non-clinical perspectives and persons with lived experience or who represent communities disproportionately affected by maternal morbidity and mortality. Cases are reviewed in a de-identified manner so as not to assign blame or trigger biases but to focus on opportunities to prevent future, similar deaths among young women. This study describes the programmatic changes that have shaped Delaware’s MMR over the last ten years, from 2015 to 2024, and their implications for the nature of the cases reviewed and findings made. The study compares two five-year periods of cases reviewed: those reviewed between 2015 and 2019, and those reviewed between 2020 and 2024. The number of cases, pregnancy relation and key characteristics of maternal deaths in these two time periods are compared and contrasted. Key findings on opportunities for systems improvement are presented in context of the programmatic strengths and limitations of MMR.
records which is a unique characteristic of Delaware’s program as it sits under the Administrative Office of the Courts and not in a public health agency like most other MMR programs across the nation. The MMR abstractor (before 2020) and the MMR Coordinator (2020 and after) are professionals with the expertise to conduct a comprehensive review of all available records and create a case summary. This case summary is de-identified, per MCDRC statute and national guidance from the CDC, and presented before a multidisciplinary Committee. The Committee reviews the de-identified case summary to answer the following key questions: 1. What were the circumstances surrounding the death? 2. What are the issues/findings that contributed to the death? 3. What recommendations does the Committee make to prevent a similar death in the future? 4. Was the death pregnancy-related? That is, was the cause of death or the chain of events leading up to the death linked in some way to the person’s being pregnant? 5. Was the death preventable?
METHODS
The Committee documents contributing factors that were important in the circumstances leading to the person’s death and drafts recommendations to address the identified factors that represent opportunities to improve the system of care. Priority recommendations identified by the MMR Committee at its annual retreat are sent forth to the MCDRC for final approval.
Inclusion Criteria
Data Analysis
This study includes cases that met the Delaware MMR eligibility criteria and were reviewed by the multidisciplinary MMR Committee between January 1, 2015, and December 31, 2024. By statute, the MMR has purview of cases that involve the death of a Delaware resident while pregnant or up to 365 days after the end of the pregnancy, from any cause. These maternal deaths are, by definition, pregnancy associated cases. Case identification processes used in the study period include: 1.) a positive response to the pregnancy checkbox question on the Delaware death certificate, meaning that the box was marked as either “pregnant at time of death,” “not pregnant, but pregnant within 42 days of death,” or “not pregnant, but pregnant 43 days to one year before death;” 2.) passive reporting by the medical examiner or a medical provider; 3.) active surveillance by MCDRC staff of Delaware obituaries that mention a decedent survived by an infant; and 4.) beginning in 2017, linkage matching the maternal identifiers on a live birth certificate or fetal death certificate with the decedent on a death certificate. Any case picked up by these methods is verified by initial review of medical records to confirm that it is a true maternal death, meaning medical records corroborate that the person was in fact pregnant at the time of death or in the year prior. Cases that are not confirmed as a maternal death by initial medical record review are deemed false positives and administratively closed.
Case Review
Cases that are true maternal deaths, that is all pregnancy associated cases, begin initial work up to include record review of all identified medical encounters in the two years prior to death. These encounters include outpatient clinics, hospitalizations, behavioral health and specialty care. The MCDRC has subpoena authority to request these medical
Cases that met eligibility criteria were divided into two groups, those reviewed by the MMR Committee between January 1, 2015, and December 31, 2019, and those reviewed between January 1, 2020, and December 31,2024. This was done to aggregate cases and have a large enough sample size for meaningful analysis. Key case characteristics were abstracted from the CDC Maternal Mortality Review Information Application database and an internal analytic Excel database maintained by the MMR Epidemiologist. These key characteristics include: 1. Race and ethnicity of the person as determined by the death certificate 2. Variables capturing the pregnancy relation decision by the Committee with options being: pregnancy associated but not related (PANR), pregnancy related (PR) or unable to determine (UTD) pregnancy relation 3. Timing of death defined by the three time periods: pregnant at the time of death, death in the first 42 days postpartum, and death between 43 and 365 days postpartum 4. Preventability as determined by majority vote of the MMR Committee with options being: preventable, not preventable or unable to determine 5. Cause of death as determined by the MMR Committee 6. Contributing factors to the death as determined by the MMR Committee The prevalence of these key characteristics among the cases defined by five-year period (2015-2019 and 2020-2024) was calculated as the percentage of cases with the characteristic out of the total cases in the time period. A Delaware pregnancy related mortality ratio was also calculated for each five-year 7
period as the number of pregnancy related cases identified in the time period per 100,000 live births occurring in the state over the five-year period. A qualitative analysis of contributing factors identified and priority recommendations reported out in each five-year period was also conducted. The MMR Epidemiologist and MMR Coordinator grouped contributing factors by CDC-defined categories to identify recurring themes. The recurring and emerging themes over multiple years are highlighted in this study.
RESULTS Process Enhancements and The Number of Maternal Deaths Reviewed 2015-2024 The number of maternal deaths reviewed annually in Delaware has ranged between four and 11 cases over the last ten years. Figure 1 shows the number of cases by year of review. Over the study’s ten-year period, there have been a total of 75 cases brought before the MMR Committee. The average time between the occurrence of a death and Committee review was about 18 months, so the cohort of cases reviewed represent deaths that occurred between calendar years 2010 and 2023.
There have also been an additional 13 cases that were administratively closed by MCDRC staff. These cases did not go before the MMR Committee and so key characteristics of the case, such as pregnancy relation and contributing factors, could not be determined. The primary reason for administrative closure of a case was that the case was at or beyond the two-year policy cutoff from the date of death. This happened in nine instances following the initiation of a vital statistics linkage process in 2017. That year, vital statistics linkage of fetal death or infant birth certificates to a maternal death certificate resulted in an additional nine cases being identified an average of 27 months after the death. These nine cases were missed under previous case identifications methods relying on the pregnancy checkbox, obituary surveillance and passive reporting. Another reason for administratively closing a case is that it was pending prosecution decision for the possible perpetrator of the death two years after the date of death. By Delaware statute, the MCDRC cannot deliberate a case that is open for prosecution.2 There were four homicide cases that were closed due to pending prosecution. Figure 1 also shows some of the key programmatic changes to MMR over the last ten years. Addition of the annual state vital statistics linkage in 2017 was followed by the 2021 addition of
Figure 1. Programmatic Changes to the Delaware MMR Over the Last 10 Years, Number of Cases Reviewed by Year, and Process Measures Reported by Time Period
8 Delaware Journal of Public Health - December 2025
monthly CDC vital statistics linkage to facilitate more timely case identification. The receipt of the CDC ERASE-MM grant in 2019 was this first fiscal support exclusively available to conduct MMR in Delaware. These funds, in the form of a five-year grant, were crucial to process improvement as they enabled the hiring of a MMR Coordinator in 2019. The MMR Coordinator is responsible for reviewing all medical and social service records, entering data into the CDC national database, writing the case summaries and supporting the functions of the MMR Committee. Prior to 2019, these duties were carried out piecemeal by volunteer abstractors and the Fetal and Infant Mortality Review Coordinator. In Delaware, the MMR Coordinator also began more actively reaching out to the next of kin identified in a case to request a family interview. The family (or close friend) interview is vitally important to provide insight on the circumstances of the woman’s life. The family interview is a proxy for the words of the woman who died on some of the conditions impacting her life and that are not often captured in medical records. When available, the family interview allows for a more holistic consideration of the circumstances leading to the woman’s death. After the hiring of the MMR Coordinator, 28% of MMR cases brought before the Committee in 2020-2024 had a family interview.
Figure 2. Number of Cases in Each Time Period by (a) Pregnancy Relation and (b) Timing of Death
Deaths by Pregnancy Relatedness
Mainly due to the addition of vital statistics linkage as a method of case identification, the total number of cases reviewed by the MMR Committee increased by 58% from 2015-2019 to 20202024. Most of the additional cases reviewed were cases that were determined to be unrelated to pregnancy, that is pregnancy associated but not related (PANR) (Figure 2). The number of PANR cases almost doubled between the two five-year periods. The number of cases determined to be pregnancy related (PR) remained the same between the two time periods, though due to the increased number of total cases in 2020-2024, the relative proportion of PR cases decreased in the later period from 34% of all reviewed cases in 2015-2019 to 20% in 2020-2024. There was a slight increase in the number of cases for which pregnancy relation was unable to be determined (UTD) by the Committee. These cases represent the gray area between PANR and PR as well as cases with larger gaps in information. Though Delaware MMR staff have power to subpoena records, some facilities do not comply with the records request, sometimes a provider or site is not known and a subpoena cannot be sent, and sometimes a provider is outside the state and beyond the MCDRC jurisdiction for subpoena. There are notable differences in the proportion of pregnancy related cases by race and ethnicity from 2015-2019 to 2020-2024 (Figure 3). Over these two five-year periods, the proportion of Black non-Hispanic women who died of pregnancy related causes decreased. In 2015-2019, Black women made up 70% of pregnancy related cases, but in the most recent period, they made up 33% of such cases. In contrast, the proportion of Hispanic women who died of pregnancy related causes increased: from 10% in 2015-2019 to 44% of pregnancy related cases in 2020-2024. The race and ethnicity composition of PANR and UTD cases did not appreciably change over the ten-year period. Hispanic women make up very few of these cases not related to pregnancy. For comparison, Hispanic women made up 19% of all Delaware live births in 2022 and Black non-Hispanic women made up 28%.3
The PRMR was calculated for each five-year period as the number of pregnancy related deaths per 100,000 live births. In 2015-2019, the Delaware PRMR was 18.6 deaths per 100,000 live births (95% confidence interval 7-30). The PRMR was not significantly changed in the later 2020-2024 time period at 17.3 deaths per 100,000 live births (95% confidence interval 6-29). The numbers of pregnancy related deaths for racial and ethnic subgroups were too small to calculate separate PRMRs based on race and ethnicity. To do this, more years of data would need to be aggregated.
Timing of Deaths
In both 2015-2019 and 2020-2024, most maternal deaths occurred in the late postpartum period six weeks to one year after the end of pregnancy. The late postpartum accounted for 45% of deaths reviewed in 2015-2019 and 63% of deaths reviewed in 2020-2024 (Figure 2). About one in five of all deaths reviewed occurred during pregnancy in both time periods. When stratified by pregnancy relation, most pregnancy related deaths (60%67%) occurred in the early postpartum, 0-42 days after the end of pregnancy. Most PANR and UTD deaths occurred in the last postpartum, with the proportion increasing from 58% to 76% between the 2015-2019 and 2020-2024 time periods (Figure 4).
Preventability
The MMR Committee votes on the potential preventability of cases using CDC guidance. Per the CDC, a case is preventable if “there was at least some chance of the death being averted by one or more reasonable changes to patient, family, provider, facility, system and/or community factors.”4 The Committee often has 9
Figure 3. Percent of Total Cases in Each Time Period by Pregnancy Relation Category and Race/Ethnicity
Figure 4. Percent of Pregnancy Related Cases by Timing of Death in (a) 2015-2019 and (b) 2020-2024.
10 Delaware Journal of Public Health - December 2025
Figure 5. Number of Cases of Substance Use Disorder (SUD) and/or Mental Health as a Contributing Factor to the Death in (a) 2015-2019 and (b) 2020-2024
not found in the earlier time period. However, among 2020-2024 pregnancy related cases, four of the nine were due to overdose (Table 1). Other causes of pregnancy related cases were often medical in both time periods: medical complications represented four of the ten PR cases in 2015-2019 and four of the nine in 2020-2024. Among cases that were PANR or UTD, overdose deaths were found in both time periods but much more prevalent in 2020-2024. One case was due to Covid in 2020-2024, and this case was determined to be PANR. To determine key contributing factors in each death, CDC guidance asks MMR Committees to look at four specific issues: obesity, discrimination, mental health and substance use disorder (SUD). Two of these issues—obesity and discrimination-were added later to the Committee deliberation guide, so the prevalence of these contributing factors cannot be assessed over the ten-year duration of this study. For the two issues assessed continuously between 2015 and 2024, the MMR Committee found that in most cases with either SUD or mental health contributing, there was an overlap with both factors contributing to the death (figure 5). The number of cases due to mental health and/or SUD increased from 15 to 32 cases in 2015-2019 to 20202024, respectively. The percent of cases with the overlap of these two issues also increased from 47% of impacted cases to 69%, where an impacted case has at least one of the issues contributing. Ninety percent of cases with co-occurring diagnoses of mental health and SUD involved women who ultimately died of overdose.
PRIORITY RECOMMENDATIONS IDENTIFIED BY THE MMR COMMITTEE to interpret what a reasonable change is. As it has gained more experience in deliberating cases, the MMR Committee has determined more cases to be preventable. From 2015-2019, 62% of all cases were determined to be preventable, including 70% of pregnancy related cases. Between 2020 and 2024, 80% of all cases coming before the MMR Committee were determined to be preventable, including 89% of pregnancy related cases.
Causes of Death
While in both the 2015-2019 and 2020-2024 time periods, overdose was the single most common cause of death reviewed by the MMR Committee, its frequency among maternal death reviews increased substantially from 28% of all cases in 2015-2019 to 61% of all cases in 2020-2024. Over the ten-year duration of the study, polysubstance use--often fentanyl in combination with another drug such as cocaine--was the most common finding at postmortem toxicology. When considering those cases just determined to be causally related to pregnancy, overdoses were
The MCDRC is required to report out on the findings and recommendations of its committees annually. Since 2015, the MCDRC annual report has included a section on the key findings, and if applicable, priority recommendations made by the MMR Committee. (For access to MCDRC annual reports, see the Reports page of the Commission’s website at: https://courts.delaware.gov/childdeath/reports.aspx.) There has been an average of four priority recommendations identified each year. A qualitative analysis of these recommendations identify some continuous and some changing themes over the course of the last ten years of MMR.
Provider Training and Quality of Care
Opportunities to improve quality of care through provider education and training have been a recurring theme since the inception of Delaware’s MMR. The MMR Committee has identified different aspects of provider education warranting focus based on cases that exemplify deviations from evidence-
Table 1. Primary Causes of Death or Manner of Death by Pregnancy Relation and Time Period 2015-2019 (number of cases)
2020-2024 (number of cases)
Pregnancy Related (PR)
Infection (2), Cardiac (2), Homicide (1), Pulmonary Embolism (1), Stroke (1), Eclampsia (1), Placenta Increta (1), Undetermined (1)
Overdose (4), Suicide (1), Infection (1), Amniotic Fluid Embolism (1), Preeclampsia (1), Ruptured Aneurysm (1)
PANR and UTD
Overdose (7), Motor Vehicle Collision (5), Homicide (2), Infection (2), Cardiac (1), Pulmonary Embolism (1), Cancer (1)
Overdose (24), Homicide (4), Motor Vehicle Collision (2), Cardiac (2), Suicide (1), COVID (1), Lupus (1), Cancer (1), Pulmonary Embolism (1) 11
based standards of care. Topics for provider education put forth by the Committee have included: the management of obstetric complications, medical transport of pregnant patients, provision of trauma informed care, recognition and reduction of implicit bias, and screening for social determinants of health.
Addressing Substance Use Disorder in Healthcare Settings
With the growing number of maternal deaths by overdose, the MMR Committee has focused over the years on ways to improve the care of women affected by SUD in the health system. The Committee’s recommendations have evolved over the past ten years from an initial focus on promoting universal screening, referral and access to treatment, to more nuanced consideration of the coordination of care between behavioral and physical health providers across different sites of care, the role of peer support specialists in engaging patients, and adopting a harm reduction approach for tertiary prevention of overdose.
Patient Education
Recommendations focusing on increasing patient/community education on health topics were more common in the 20152019 period. The MMR Committee increasingly came to see the provision of standardized education as an asset to share pertinent information at important times in the perinatal period. Facilitating patient education during prenatal care and hospital delivery discharge were two time points of particular importance. To create tools for the clear presentation of key information on symptoms warranting immediate or emergent action by a pregnant patient, the MMR staff worked with the Division of Public Health on the Urgent Maternal Warning Signs project. These patient-facing materials became available in 2022 free of cost to distribute via clinics and hospitals. Providers can order and reorder materials as needed on the DEthrives.com website in English, Spanish and Haitian Creole.
Care Coordination
Care coordination has emerged as a prevalent theme in the 2020-2024 time period. Given the complexity of issues affecting women who died in the peripartum, the MMR Committee has increasingly come to identify gaps in the coordination of care needed to address issues across the physical health, behavioral health and social domains. The MMR Committee has considered the reimbursement aspect of care coordination, staffing issues such as who can do this work, and the sites or transition points where it is needed, for example upon hospital delivery discharge. The role of birthing facilities, Medicaid managed care organizations and the Department of Corrections has also been highlighted in recent recommendations relating to this theme.
DISCUSSION The MMR program in Delaware has been evolving since its inception in 2011 but has continuously strived for nationally guided, in-depth, multidisciplinary reviews of all identified pregnancy associated deaths that meet mandated eligibility criteria. One of the key process changes that occurred in 2017 was the addition of state linkage of fetal death and infant birth certificates to death certificates of women of childbearing age as a means of case identification. This process change immediately picked up nine additional cases that had not been previously identified by the pregnancy checkbox response question on 12 Delaware Journal of Public Health - December 2025
death certificates. It is not surprising that some cases were being missed by use of the pregnancy checkbox as the primary means of case identification. Several jurisdictions have reported on the sensitivity of the pregnancy checkbox question as being around 60%, meaning that only about 60% of true pregnancy associated deaths are picked up by that single question on the death certificate.5,6 Many times, the death certifier may be unaware of a woman’s pregnancy history and so the question on timing of death in relation to pregnancy is filled out incorrectly, resulting in false positive responses as well as false negatives. Unfortunately, the nine additional cases that were picked up in 2017 were more than two years out from the date of death, and so they could not undergo a full Committee review. The addition of the annual vital statistic linkage process had the effect of picking up more pregnancy associated deaths, especially those occurring in the late postpartum period several months out from the end of pregnancy. This is reflected in the increased numbers of PANR cases and late postpartum cases reviewed in the 2020-2024 time period compared to 2015-2019. Subsequent to the addition of the state vital statistics linkage process, the CDC facilitated a monthly vital statistics linkage in 2021. While this CDC linkage has allowed more timely identification of cases through linkage, it has not altered the total number of cases brought before the MMR Committee or time to review substantially. The Delaware MMR Committee has also been on an evolving journey in its understanding of best practices to review a maternal death. Growing familiarity with the key definitions in the process of deliberation has resulted in more standardized reviews. CDC funding through the ERASE-MM grant, beginning in 2019, enabled the hiring of a dedicated MMR Coordinator. In addition to conducting thorough and high-quality abstractions, the Coordinator was also responsible for conducting family interviews, and 28% of 2020-2024 cases had this additional, key perspective offering invaluable insights on the women’s lives from family members, partners or close friends. CDC grant funding also created more collaboration between grant recipients operating across the country. Participation in the CDC-led communities of practice has helped Delaware staff and MMR Committee members learn from other jurisdictions and adopt promising practices. Consideration of pregnancy relation in cases of overdose and suicide, in particular, has been a growing edge for the MMR Committee. One seminal change was the adoption of the Utah criteria for review of these deaths.7 The Utah criteria consider how events often found in histories involving mental illness and substance use disorder may be considered in the framework of pregnancy relation. The Delaware MMR Committee members were trained on this framework in 2021, and since then more cases involving overdose have been deemed pregnancy related. Another process change that impacted the deliberation of cases involving mental health and substance use disorder has been the evolving membership of the MMR Committee. Beginning with the receipt in 2019 of CDC grant funding to support the Delaware MMR program, CDC guidance required a 60:40 ratio of clinical to nonclinical members. This led to MMR staff recruiting more behavioral health experts, social workers and persons with lived experience to join the MMR Committee. The input of these members has helped move the group to a
more holistic consideration of women’s health that includes their mental and social well-being. Then in 2022, as part of the Delaware Momnibus package, which also formally changed the name of the Child Death Review Commission to the Maternal and Child Death Review Commission in recognition of the important work of MMR, the Commission was required to add a licensed mental health professional, a maternal advocate, a child advocate, and a certified nurse midwife to its membership and a community member to the MMR Committee membership.2 Broadening the expertise and representation of persons with lived experience in the MMR Committee has resulted in more nuanced considerations of the contributing factors and experiences of women dealing with behavioral health and social risks. While process changes have improved the quality and thoroughness of the MMR program, the MMR program has continuously been the source of the most in-depth consideration of maternal deaths in Delaware since it began in 2011. The findings—including the determination of pregnancy relatedness in the eligible deaths reviewed—provide the most detailed insights on the causes and conditions of maternal deaths in Delaware. Because the Delaware MMR has access to medical records, as well as other social service and criminal justice records, and in some cases a family interview, the reviews have the most well-rounded view of the circumstances leading up to the death. Hence the MMR program provides the most accurate count of pregnancy related deaths in the state. Based on the last ten years of review, the PRMR has not significantly changed over the two five-year time periods presented here. The Delaware PRMR was 18.6 per 100,000 live births in 2015-2019 and 17.3 per 100,000 live births in 2020-2024. These estimates are similar to the U.S. PRMR of 18.7 deaths per 100,000 live births for 2023.1 However, the MMR program’s PRMR is likely an underestimation in Delaware. Current case identification methods are still likely missing those maternal deaths that occur early in pregnancy or following a miscarriage or abortion. A fetal death certificate is not issued in any of these scenarios, so they are not picked up by vital statistics linkage. Only if the certifier of a death knows the woman’s recent pregnancy history, there may be a chance the pregnancy checkbox question is accurately completed. Other jurisdictions employ additional case identification processes to increase thoroughness of case ascertainment including linking death certificates with hospital discharge data and/or Medicaid claims data. A pilot of adding these methods in Delaware’s MMR process may be helpful to assess their feasibility and the additional number of cases that would have been missed by the current, established processes. Procedural limitations also contribute to the likely underreporting of Delaware’s PRMR. The MCDRC’s policies preclude cases that are two years out from the date of death to go before the MMR Committee, and so there is no vote on pregnancy relation. Also, cases with pending prosecution decisions two years after the death do not go before the Committee. Homicide deaths are the most common type in this latter category, and so their pregnancy relation status is not determined. There were four homicide cases that did not get a Committee review in the last ten years due to pending prosecution. Finally, there were eight cases (two in 2015-2019 and six in 2020-2024) that were voted on by the Committee as unable to determine pregnancy relation due to incomplete information.
The MMR program in Delaware is crucial to a thorough consideration of all deaths during and up to one year following the end of pregnancy from any cause. The determination of pregnancy relation classifies deaths into those causes linked to a woman’s being pregnant. These pregnancy related deaths offer key insights into the care of women in the peripartum, obstetric standards of care, and variations in practice that may put some communities or groups of patients at higher risk of obstetric complications and death. Equally vital in the MMR’s work is its thorough and in-depth deliberation of cases not causally linked to pregnancy, because these cases represent the causes of death impacting all young women. Since these causes of death are not pregnancy related, all women—whether or not they are pregnant—are the population at potential risk. Overdoses, motor vehicle collisions and homicides are the top three causes of death that were reviewed and determined to not be related to pregnancy. Understanding some of the associated risk factors in these cases and tailoring prevention strategies to address these risks have the potential of yielding the biggest public health impact as the population at risk is larger. Overall, the highest intersection of risk factors in maternal death cases is the overlap of mental health, substance misuse/abuse and social risks such as history of trauma, violence, or unstable housing. The Delaware MMR offers an opportunity to look at both pregnancy related and pregnancy unrelated cases in great depth and in a holistic way to consider the systems of care, how they relate across sites of care and time, and where opportunities lie to make sure fewer women fall through the cracks.
PUBLIC HEALTH IMPLICATIONS • Maternal mortality review (MMR) offers the most comprehensive, holistic consideration of deaths that occur among women while pregnant or up to one year after the end of pregnancy, irrespective of cause. A key function of the MMR Committee is to determine if the death is pregnancy related—causally linked to the woman’s being pregnant—or not. Deaths that are not related to pregnancy are defined as pregnancy associated but not related (PANR). • The MMR Committee’s findings, contributing factors and recommendations for PANR cases are vitally important as these are causes of death that may affect all young women, pregnant or not. The larger vulnerable population size makes these PANR causes—overdose, motor vehicle collisions and homicides—important public health issues. • The work of the Delaware MMR has identified the intersection of three categories of risk that identify women most likely to experience a maternal death; these are women with the co-occurrence of mental health conditions, substance misuse/abuse and social risk such as traumatic experiences or exposure to violence. • To meet the needs of women at highest risk of maternal death, we need to break down silos and increase connections between medical, behavioral health and community-based programs to ensure women have longitudinal care and get the support they need. 13
• Ongoing education for providers and patients can ensure more consistent standards of care that reflect evolving practices and promote patient engagement. In particular, women’s health providers can adapt to help meet the growing need to address perinatal mental health and substance use as causes of preventable mortality.
ACKNOWLEDGMENTS We would like to acknowledge the dedication and commitment of our MMR Committee members, especially the leadership of Dr. Garrett Colmorgen and Dr. Vanita Jain. We also could not do this work without the vision and support of our current MCDRC Executive Director, Kimberly Liprie, and former director, Anne Pedrick. Finally, a special thanks to our current MMR Coordinator Jacqueline Corbin-Armstrong, who continues to pursue the highest standards for our team. Dr. Ramakrishnan may be contacted at: meena.ramakrishnan@delaware.gov.
REFERENCES 1. Centers for Disease Control and Prevention. (2025, April 29). Data from the pregnancy mortality surveillance system. Maternal Mortality Prevention. https://www.cdc.gov/maternal-mortality/php/pregnancy-mortality-surveillance-data/index.html 2. Maternal and Child Death Review Commission. (2025). Title 31 Welfare; Chapter 3 Child Welfare; Subchapter II. Retrieved from: https://delcode.delaware.gov/title31/c003/sc02/index.html 3. Delaware Health Statistics Center. (2024). Delaware vital statistics annual report, 2022. Delaware Department of Health and Social Services, Division of Public Health: 2024. Retrieved from: https://dhss.delaware.gov/dph/hp/annrepvs/ 4. Centers for Disease Control and Prevention. (2025, May). maternal mortality review committee decisions forms v24.3. Maternal Mortality Review Information Application: 2024. 5. Catalano, A., Davis, N. L., Petersen, E. E., Harrison, C., Kieltyka, L., You, M., . . . Goodman, D. A. (2020, March). Pregnant? Validity of the pregnancy checkbox on death certificates in four states, and characteristics associated with pregnancy checkbox errors. American Journal of Obstetrics and Gynecology, 222(3), 269.e1–269.e8. https://doi.org/10.1016/j.ajog.2019.10.005 6. Horon, I. L., & Cheng, D. (2011, Mar-Apr). Effectiveness of pregnancy check boxes on death certificates in identifying pregnancy-associated mortality. Public Health Rep, 126(2), 195–200. https://doi.org/10.1177/003335491112600210 7. Smid, M. C., Maeda, J., Stone, N. M., Sylvester, H., Baksh, L., Debbink, M. P., . . . Metz, T. D. (2020, October). Standardized criteria for review of perinatal suicides and accidental drug-related deaths. Obstetrics and Gynecology, 136(4), 645–653. https://doi.org/10.1097/AOG.0000000000003988
Qualitative PFAS Health Study We are inviting community-based primary care clinicians who work in the Delaware River Valley to participate in a study to assess how the ATSDR clinical information factsheet is used in real-world applications of PFAS clinical prevention and management for children. Participation involves being interviewed once, for approximately one hour. Your insights will contribute to our understanding of the evolving needs of community-based primary care clinicians working with PFAS, potential equity gaps, and policy challenges. Your participation is completely voluntary. There is no compensation for participation. If you are interested in participating or have any questions about the study, please contact Emma Pennea at pennea.emma@gmail.com.
We are seeking participants who meet the following criteria: • Community-based primary care clinicians (including physicians, advanced practice registered nurses, and physician associates), • Serves communities in the greater Delaware River Valley, • And has encountered children with suspected or confirmed exposure to PFAS.
Emma Pennea (IUI) Doctoral Candidate DrPH Program at Richard M Fairbanks School of Public Health Indiana University - Indianapolis 14 Delaware Journal of Public Health - December 2025
For Parents and Other Caregivers: Understanding Hepatitis B and the Hepatitis B Vaccine What is Hepatitis B (Hep B)? Hepatitis B (Hep B) is a viral infection that causes swelling in the liver. Some people infected with Hep B experience a shortterm illness, also called acute Hep B. Symptoms include fever, fatigue, loss of appetite, nausea, jaundice, and pain in the muscles, joints, and stomach. Acute Hep B can lead to chronic Hep B, a long-term illness that can cause liver damage, liver cancer, liver failure, and death. 90% of newborns and babies infected with Hep B will develop chronic Hep B. Chronic Hep B is fully preventable through vaccination, which infants can receive at birth. A person with active or chronic Hep B can pass the infection to another person, including infants, through blood and other bodily fluids. Infants can contract Hep B during birth if the parent giving birth has Hep B. A person may also contract Hep B if they share razors, toothbrushes, and needles with a person who has Hep B, if they come into contact with the blood of a person who has Hep B, or if they have sex with someone who has Hep B. While most people with chronic Hep B do not have symptoms, they can still spread the disease to others. Between 850,000 and 2.2 million people in the United States are living with chronic Hep B.
Protecting Yourself and Your Child from Hep B and Liver Cancers Caused by Hep B You can prevent Hep B infection and its most serious potential effects, like cancer, by getting yourself and your child vaccinated. Most people who receive the Hep B vaccine are immune for life. The Hep B vaccine is available to anyone ages 59 or younger, as well as to people ages 60 and older who are at an increased risk of Hep B exposure and were not vaccinated previously.
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Infants, babies, and children who contract Hep B are 80-85% more likely to experience chronic Hep B and its severe symptoms than adults who contract Hep B. Early vaccination is an essential step for lifelong liver health. The American Academy of Pediatrics recommends that all infants receive their first dose of the Hep B vaccine at birth. The birth dose is an essential part of preventing long-term Hep B illness in infants. Babies can then complete the vaccine series by getting the second dose of the Hep B vaccine at one to two months old and the third dose at six to 18 months old. Most people do not need a booster dose of the Hep B vaccine later in life. All infants, regardless of their parent’s Hep B status, should get the birth dose of the Hep B vaccine and two additional doses by 18 months old.
Note: In December 2025, the U.S. Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) recommended that parents who test negative for Hep B engage in individual-based decision-making with a healthcare professional before their baby receives the birth dose of the Hep B vaccine. Individual-based decision-making is a conversation between a parent or patient and healthcare professional to help inform treatment plans. An individual-based decision-making recommendation does not impact your ability to access the birth dose for your baby. If you have insurance, an individual-based decisionmaking recommendation also shouldn’t impact coverage of your vaccine. Additionally, ACIP now recommends that parents ask their healthcare professionals about getting their child an antibody blood test before they receive the second and/or third doses of the Hep B vaccine. However, these tests cannot reliably report whether a child has long-term protection against Hep B after one dose of the vaccine. These tests also require additional infant blood draws and potentially higher costs for families, without a guarantee that they will provide useful information. Many public health experts have expressed concerns that this ACIP recommendation, which lacks evidence, will unnecessarily delay or otherwise hinder access to the Hep B vaccine for some infants, which could put them at higher risk of infection and the lifelong impacts of such infection. This resource recommends following the AAP’s recommendations because they are accurate, scientifically rigorous, and timely.
Additional Facts About the Hep B Vaccine Getting the Hep B vaccine at a very early age provides effective, lifelong protection against liver damage, liver failure, and liver cancer. •
The Hep B vaccine prevents serious illness from all types of transmission. Hep B is often thought of as a sexually transmitted disease, but it is also transmitted in other ways, such as from a parent giving birth to their newborn. The risks of Hep B infection in an infant are much higher than the risks of Hep B infection in an adult. This is why the American Academy of Pediatrics recommends that infants receive their first round of the Hep B vaccine within 24 hours of birth and two additional doses by 18 months old to complete the 3dose vaccine series. Often, people don’t know they have Hep B because they
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don’t have symptoms. Even without symptoms, Hep B can be transmitted and result in liver damage, liver failure, liver cancer, and death. The Hep B vaccine is 90-95% effective at preventing chronic Hep B infection. Like all vaccines, the Hep B vaccine is continuously monitored by government agencies and non-government health experts through various reporting systems, safety assessments, and collaboration. The Hep B birth dose is administered in countries across the globe. Among the World Health Organization’s 194 member states, 115 have adopted its recommendation to give infants a dose of the Hep B vaccine at birth. Some countries suggest delaying the first dose of the Hep B vaccine for babies whose parent tests negative for Hep B, but those countries often have alternative prevention tools that the United States lacks, such as universal Hep B screening and testing for pregnant people. The Hep B vaccine does not cause autism. Getting the Hep B vaccine may cause mild symptoms, including soreness and swelling at the site where the shot was given. However, studies have repeatedly found no link between autism and vaccines like the Hep B vaccine or the vaccine preservative thimerosal.
Hep B Vaccine Next Steps Discuss any questions you have about Hep B and the Hep B vaccine with a healthcare provider. If your child hasn’t yet received the Hep B vaccine or did not complete the full vaccine series by 18 months old, consider scheduling an appointment with a healthcare provider to discuss next steps.
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Historical Claims Literature Review Paper: Black Maternal Health Jasmine R. Hilliard, L.S.C.W. Department of Social Work, Delaware State University
ABSTRACT Mistrust among Black women toward the medical system is evident across many eras of reproductive history, and the generational mistreatment of their reproductive health continues to harm their mental well-being and family health in the 21st century. Even with the advancement of modern medicine, Black women and babies are dying at a higher rate than other ethnic groups. Medicine has long been used to stereotype Black women’s physical and emotional resilience, sexuality, and capacity for motherhood. The interplay of race, socioeconomic power, and institutional knowledge has worked to preserve an inequitable and oppressive framework governing Black women’s reproductive rights. This article reviews literature on the history of reproduction as it relates to Black women, as well as studies examining culturally sensitive approaches aimed at improving provider–patient interactions and reducing maternal and infant mortality. The results indicate that historical constructions of race and the persistence of racial stereotypes continue to shape the practices of today’s medical professionals. By understanding how these stereotypes developed and how they intersect with race and socioeconomic status, we can foster new frameworks that improve outcomes for Black women and their families.
INTRODUCTION Throughout history there has been an exploitation of Black women’s reproductive rights, a generational impact of scientific racism that has fostered deep mistrust in the medical system, and vast negative effects on Black maternal health. The historical exploitation of Black women’s reproductive rights, how race has shaped biomedical knowledge and clinical practice, and the generational impact of scientific racism has fostered deep mistrust in the medical system. The reproductive health struggles of Black women have persisted as a deeply rooted and often overlooked issue since the forced transportation of African people to the New World. Within this broader context, the topic of Black maternal health has received even less attention, remaining under-researched and underrepresented across social and advocacy platforms. American history is stained by the abuse of Black women’s bodies, from forced reproduction to generate wealth, using the Black body for experimentation in acquiring knowledge, to the push of sterilization in the need to reclaim a “pure race.” Medicine has been used to stereotype the Black woman’s physical and emotional endurance, sexuality, and ability to mother.1 Understanding the disparities experienced by African American women is crucial for creating effective interventions, breaking systemic patterns of medical neglect, and developing supportive systems. Maternal mental health plays a vital role in shaping the well-being of both African American mothers and their families. 18 Delaware Journal of Public Health - December 2025
HISTORICAL CLAIMS OF WEALTH, KNOWLEDGE, AND RACE: THE WHITE MAN’S CLAIM TO REPRODUCTION Wealth With the abolition of the trans-Atlantic slave trade in 1808, slaveholders were confronted with a new challenge: how to sustain and expand the enslaved labor force without continued importation from African nations. Roughly three to four million Africans survived the Middle Passage and settled in the southern states of America.2 During this period, the early nineteenth century, the reproductive health of enslaved African women became an area of intense interest and control. The concept of reproductive property gave rise to the practice known as “slave breeding,” further entrenching the dehumanization of African people as chattel. Enslaved women were routinely sexually exploited and forced to bear children.3 Childbearing of slave women became the primary source of fortifying new field hands. Under American law, the child inherited the status of their mother, thus even children born of the slave master’s blood became an enslaved person.4 The legalization of slave breeding under the principle “partus sequitur ventrem” not only actualized the inheritance but guaranteed that status to their descendants as well.5 The legal system also absolved enslavers of rape, stating this act was not illegal given the property status of slave women. Washington4 writes that President Thomas Jefferson stated he considered breeding slave women who could Doi: 10.32481/djph.2025.12.04
produce a child once a year just as profitable as a field hand. In the late 1800s, women of childbearing age (those of menstruating years as young as 12) were sold on the slave block for as much as $1,600, modern-day equivalent of $45,000-60,000.6 While family births were typically written in the family bible, the births of enslaved babies were recorded in the salve holder’s plantation business records.3
Knowledge Midwifery, once a role traditionally held by women, began to shift into the hands of White male physicians. Initially, men viewed childbirth as a private, female-centered domain; however, as economic motives intertwined with medical practice, increasing numbers of White men entered the field.4 These physicians became integral figures within slaveholding communities, recognizing the financial and political benefits of their involvement. Physicians in this new field began as personal doctors to plantation owners. The Black woman’s body became an integral part of medical science, feeding American research, medical training, practices, and theories.7 Reproductive medicine thus became deeply embedded in the institution of American slavery. Enslaved women’s bodies were subjected to invasive and experimental medical procedures without consent. These experiments included studies on pubescent menstruation, cesarean deliveries, surgical repair of vaginal tears during childbirth, removal of uterine cancers, and treatments for internal injuries caused by sexual violence.7 James Marion Sims, often called the “father of gynecology,” is recognized for founding the first women’s hospital, developing surgical techniques to repair vaginal fistulas, and addressing complications that hindered childbirth.8 Sims conducted his experiments on twelve enslaved women, some as young as fourteen, performing repeated procedures without anesthesia. Francois Marie Prevost developed the cesarean section, a procedure done when a vaginal birth is not optimal, through continued experimentation on enslaved Black women in America.8 Medical doctrine of the 18th and 19th centuries from the British West Indies was a significant platform for the treatment of the enslaved women of childbearing age. Scottish physician James Grainger, a colonial physician in the British West Indies, wrote essays on the women of the “Ibbo” country. His essays were contradictory in nature: Graniger described this group of women as incurable, barren, less fertile than “White” women, and with many disorders. However, he also concluded that Black women were less susceptible to complications during birth.9 Infant mortality was a primary focus for many physicians; many White doctors blamed the high infant mortality rate on the enslaved women and not the unsanitary conditions throughout pregnancy and birth. In the Southern states of America, a probable 50% of enslaved infants died within the first year of life.5 Physician Robert Thomas of the West Indies wrote that Black women were unsafe in their decision-making, thus needing “supervision” to avoid endangering their newborn child. Thomas, in his writing, further perpetuated the idea of immorality and hypersexuality of Black women, suggesting they carry disease in their blood because of prostitution.5 “Practical Rules for the Management and Medical Treatment of Negro Slaves, the Sugar Colonies,” written by Dr. Collins in 1803,
was used by plantation owners throughout the West Indies and the Americas. Collins’ assumptions of how to treat the health of Black women created an attitude of dismissiveness in the birthing room of the slave woman.9 By the late 1800s, doctrine and treaties fortified the stigma of Black women in these key areas8: • Hypersexuality and promiscuity, • Having a high tolerance for pain, • Requiring less need for medical care, • Considered lazy in their parenting, • Incompetent, • Irresponsible, and • Requiring management and oversight of their reproductive health. The post-emancipation South ushered in a new era of racial dominance through the establishment of Jim Crow laws. These legislative measures institutionalized the rigid segregation of White and Black Americans, reinforcing a deeply divided society. Furthermore, such laws perpetuated the systematic disenfranchisement of Black citizens, depriving them of fundamental civil and political rights. A woman who was once valued for her ability to produce children for economic gain became vilified for that same capacity.3 As this shift occurred, a campaign for the sterilization of Black mothers began. Margaret Sanger, the founder of the American Birth Control League and a celebrated feminist and birth control advocate has been identified as an underlying proponent of the sterilization of Black women.3,4 Sanger also endorsed the pseudoscientific theory of eugenics. Eugenics posited that intelligence and personality traits were determined by genetics, reinforcing the belief that racial characteristics were hereditary and fixed. Through so-called physiological evidence, eugenics was used to justify the perceived inferiority of Black people.4 These ideas profoundly influenced legislation and justified government involvement in the reproductive lives of Black women.4 Birth control pills were distributed to poor Black women at little to no cost through reproductive health clinics (like Planned Parenthood) concentrated in Black neighborhoods. By the 1960s, organizations such as the NAACP and leaders within the Black Power movement began denouncing birth control initiatives, viewing them as instruments of racial genocide.4 Additional forms of birth control were imposed upon Black women, including the intrauterine device (IUD), a contraceptive implant that thickens the uterine lining to prevent fertilization. The IUD became known as a “silent killer,” as research revealed that Black women were disproportionately affected by fibroids, endometriosis, and cancer. Rather than alleviating these health issues, the IUD often worsens them, leading to infections and infertility.4 Seeking to guarantee the sterilization of Black women, in 1993 Governor William Schaefer of Maryland proposed that Norplant (another long-acting birth control method inserted into the arm) be implanted in every woman on welfare as a mandate.3
Race It is a striking contradiction that Black women were considered capable of nurturing and raising White children, yet were viewed as unfit to care for their own. Following the Emancipation Proclamation of 1863, which declared enslaved people in Confederate states free, this paradox became even more 19
pronounced. Since the Victorian era, enslaved African women have been portrayed as hypersexual and excessively fertile compared to White women.3 These racist stereotypes shaped the perception of the Black family, suggesting that Black women’s supposed sexual promiscuity made them dangerous in their mothering, and that they would pass on hypersexual behaviors to their children, destabilize the Black family structures, and incite Black men to sexually assault White women.3 Divorce rates in the antebellum South escalated as adultery became a primary reason for the White wife to petition the court. Molloy writes that White women unknowingly or knowingly played a part in the degradation of Black women.10 It was not an uncommon practice for slaveholders to rape or have adulterous relationships with their enslaved women; this was known to the White woman as she witnessed these dealings in her own upbringing, oftentimes playing with her “mulatto” siblings. Further solidifying herself in the racial hierarchy, White women used terminology in their court appeals, reinforcing the hypersexual stereotypes and placing blame on the Black woman for the sexually abusive relationships they were forced into. Petitions encompassed verbiage such as “wench,” “mulattress,” and “prostitute.” The use of this language contributed to the culture of rape of Black women, whilst diminishing the responsibility of the perpetrator, the White man.10 In 1910, Abraham Flexner was commissioned by the Carnegie Foundation to assess the educational components of medical school in America and Canada. The goal was to streamline medical professionals’ teaching practices, produce practitioners with better technical and clinical knowledge, and reduce the number of poorly educated physicians.11 What seemed like an assessment to streamline the medical education field really alienated persons based on race, region, and gender. Flexner’s report sought to define a single type of person qualified for the medical field: the Northern, affluent, White male. In 1908, there were 150 medical schools in the United States and Canada, and after his assessment, only 31 institutions were deemed of standard. Of the seven programs for Black students, Flexner considered only two sufficient: Meharry Medical College in Nashville, TN, and Howard Medical School in Washington, D.C.11 Flexner did not believe Black men specifically should be educated to practice medicine with all groups, but rather to treat Black Americans in the area of community health. Flexner, in his report, did not even consider Black women to be optimal candidates for admission to medical school Sterilization has long functioned as a central mechanism of reproductive control in the United States. This was evident during the “crack baby” era of the 1980s and early 1990s, when many pregnant women were incarcerated and subsequently subjected to involuntary sterilization.3 Similar patterns emerged during the Clinton administration, when welfare reforms implicitly encouraged the use of birth control through changes to eligibility requirements and the introduction of time limits. Despite rising numbers of employed and college-educated Black women, sterilization rates remain disproportionately high: 9.7% of Black women have been sterilized compared to 5.6% of White college-educated women.3 Today, Black women face additional reproductive injustices, including significantly elevated risks of maternal and infant mortality. In the United States, Black women are four times more likely than White women to die during labor and delivery, even when experiencing comparable medical conditions.12 20 Delaware Journal of Public Health - December 2025
HISTORICAL INTERSECTIONS IN CURRENT DAY PRACTICE: THE CONTINUED SILENCING OF THE BLACK MOTHER A 2022 article titled “I Just Want to Be Heard” highlighted concerns among a group of 31 Black women. Participants described consistent experiences of being ignored or met with negativity and a lack of empathy from physicians and nurses during various stages of pregnancy, including the perinatal, delivery, and postpartum periods.13 Many reported feeling dismissed when voicing any concern. The women also discussed mental health challenges, noting experiences of depression and anxiety during and after pregnancy. They shared the difficulty of managing household responsibilities while coping with postpartum depression, emphasizing that their interactions with healthcare providers often worsened their mental health.13 Montalmant and Ettinger conducted a literature review on the racial disparities in maternal mortality and the impact of racism and implicit bias.14 The authors reviewed the literature dating back to 1946 to improve obstetric outcomes. They detail that, while the American medical institution recognized the disparities in health outcomes amongst women of color compared to White women, little has changed throughout the decades. Key findings in the literature review focused on pain management, poor communication, implicit bias in treatment plans and outcomes, and a lack of ownership from the practitioners of their racial behaviors and bias. One study reviewed found that 63% percent of Black women receive an epidural for pain management compared to white women at 74% - the results suggested that the anesthesiologist took longer to initiate the procedure. Further information gathered found that medical students and residents held false narratives of biological difference between Black and White women, including the idea of their threshold for pain; this is congruent with the historical perspective stemming from slavery. Due to this bias, health care professionals are prone to disregarding pain complaints, thus providing deficient treatment.14 Montalmant and Ettinger also reviewed a study of the “Listening to Mothers II survey.”14 It found that Black women experienced more challenges with communication in their prenatal care. Reports stated that physicians were more verbally dominant in their conversations with Black women compared to White women, and appointment times were 33% shorter. Black women also reported being advised on permanent contraceptive measures regardless of their number of children. Other studies noted doctors were surveyed on disparities in their practice, with most denying implicit bias and racist behaviors affecting how they care for their patients.14 In 2022, the Women’s Health Report published an article titled “Clinicians’ Perspectives on Racism and Black Women’s Maternal Health.” The study examined the views of sixteen White maternal health practitioners, focusing on inequities in maternal care between Black and White women in the San Francisco Bay Area.15 Findings revealed that stereotypes and racial biases about Black mothers influenced the quality of care they received. Some healthcare facilities reported that these beliefs affected the medical options offered to Black women after childbirth. Additionally, practitioners acknowledged that racial biases hindered their ability to actively listen to Black patients, leading
to instances where patients were dismissed or excluded from discussions about their own care. While participants recognized that racial ideologies have historically shaped reproductive health practices, many struggled to identify how their own implicit biases affected their treatment of patients.15
ABSENCE OF BLACK PHYSICIANS AND HEALTH CARE PROVIDERS In the United States, African Americans represent only about 5% of practicing physicians.1 This underrepresentation extends across other healthcare professions, including psychiatry and therapy. Although African Americans make up roughly 14–15% of the US population, their presence in the mental health field remains disproportionately low. Addressing the Underrepresentation of African American Mental Health Professionals reports that African Americans comprise just 2% of psychiatrists, 4% of psychologists, and 22% of social workers, with additional studies noting that only 4% of social workers are licensed counseling professionals.16 A 2024 study using data from the Association of American Medical Colleges further identified racial and gender disparities in obstetrics residencies.17 In 2021, the number of female residents increased overall; however, White women experienced an 8% increase in applications, compared with a 3% increase among African American women. Meanwhile, male representation declined by 15% across all racial groups.17
PRACTICE, POLICY ADVOCACY, OR COMMUNITY ENGAGEMENT The health of Black women has been profoundly and persistently harmed by the actions and systems established by White Americans. Throughout history, science, medicine, genetics, and sociology have been misused to promote false narratives that served economic and political interests. The resulting mistrust Black women hold toward the medical establishment is rooted in these repeated injustices across multiple eras of reproductive history. The question, for decades, remains: how do we make sustainable change? Many articles describe similar systematic approaches to improve maternal health outcomes for Black women and their infants. The key findings suggest18: • Training in culturally responsive, individualized, patient-centered care; • The establishment of healthier patient-provider relationships; and • Providers engaging with the communities they serve. The findings also highlighted the need to increase patient education and awareness within the healthcare system, along with diversifying the maternal healthcare system.14
A NEW WAY FORWARD: BLACK PROFESSIONALS IN THE ROOMS In Cleveland, Ohio, a nonprofit, Black-owned organization opened a practice called Birthing Beautiful Communities (BBC). The BBC’s structural understanding focused on the impact of historical trauma, systemic racism, and inequities in Black communities.19 The organization’s goal is to reduce the infant mortality rate for Black women. The program provides pregnant
women with a Perinatal Support Professional (PSP) who follows them through pregnancy, birth, and up to one-year postpartum.19 Analytical results from BBC interviews found that PSP helped bridge the communication gap between patients and providers. Women reported that PCPs helped them better understand medical terminology, assisted with translating and clarifying difficult information, helped create a space to ask more informed questions, and improved overall understanding of treatment and diagnoses. The women reported that PSPs helped them be seen and heard by the medical profession by providing encouragement, advocating on their behalf, and empowering them to have a say in their care. Lastly, the women reported a trusting relationship with their PSP. These relationships created a safe space and addressed the women’s needs holistically.19 Interviewees noted a dramatic difference in interactions with the physician when the PSP did not attend, further suggesting the implicit bias that practitioners hold toward patients.
For Us By US: Building Our Own Programs The Healthy Birth Initiative Program (HBI) of Portland, Oregon, a program like BBC, has expanded its services into the homes and communities of its Black pregnant patients. This program provides services from pregnancy through the child’s 18th month.20 It includes in-home case management, home nurse visits, mental health services, and other health care specialists in the areas of breastfeeding, coordination with community services, and material support. The program uses a culturally specific approach to advocacy.20 An added benefit of the HBI program is its ability to triage health complications, promote prenatal care, teach women how to engage with medical providers, and serve as a liaison team. Interviewees in this program shared similar experiences to the women in the BBC program: poor communication with health care providers, feeling exploited, lied to, disbelieved, and endorsed microaggressions from providers.20 Interviewees shared that being part of a program where professionals looked like them reduced overall stress; these women felt understood and that the staff cared about their best interests. Dulas attending doctors’ appointments had a successful impact on improving health outcomes. Recommendations from participants to add into the program were support groups to address stress related to racism, birthing trauma, and reduce isolation in a safe space.20
LIMITATIONS: ONCE AGAIN, THERE IS NEVER ENOUGH OF US While this author would recommend policy changes that have a significant impact for Black women and that improve mortality rates for both mom and infant, I believe a boots-on-the-ground method would be the best approach to address this immediate crisis. The programs mentioned above appeared to have success with their predominantly represented and culturally specific methods for addressing maternal health disparities. While more of these programs should be replicated to test the success rate and overall improvement outcomes, limitations exist. Programs with all-Black staff may be complex to build in enough regions of America to reach this specific population of women. According to the literature, there is a lack of representation of Black providers in the field that would hinder the further development of these programs. The primary conclusion of most of the studies suggests an acknowledgement of the racial ideologies, practices, and beliefs held by White health care providers. Conclusive results suggested that White health care providers should engage in trainings that address racial and implicit bias. 21
CONCLUSION Europeans developed a system in which racism operated as a tool to uphold unequal power structures, ensuring that those at the top remain privileged at the expense of others. Race itself is a constructed idea, created by groups seeking to secure power and resources. Throughout history, literature and doctrine have promoted false narratives about African people to justify their oppression. The strategic misuse of medicine, science, and genealogy has been especially influential in manufacturing and reinforcing notions of superiority. The mistrust of the Black women in medicine can be seen through the many eras of reproductive history. The effects of generational mistreatment of Black women’s reproductive health continue to have a negative effect on her mental and familial health. As a result, there continues to be a racial gap in the mortality rate of Black women and their babies. Ms. Hilliard may be contacted at jrhilliard09@students.desu.edu.
REFERENCES 1. Rainford, M. (2003). Pregnant while black. Augsburg Fortress Publishers. 2. Kendi, I. X. (2017). Stamped from the beginning: the definitive history of racist ideas in America. London: The Bodley Head. 3. Roberts, D. E. (1997) Killing the black body: race, reproduction, and the meaning of liberty. Vintage Books. 4. Washington, H. A. (2006). Medial apartheid: the dark history of medical experimentation on the black American from colonial times to the present. Paw Prints. 5. Owens, D. C., & Fett, S. M. (2019, October). Black maternal and infant health: Historical legacies of slavery. American Journal of Public Health, 109(10), 1342–1345. https://doi.org/10.2105/AJPH.2019.305243 6. Hummel, J. (2014). U.S. slavery and economic thought. Econlib. https://www.econlib.org/library/enc/usslaveryandeconomicthought.html 7. Schwartz, M. J. (2006). Birthing a slave: Black mothers and white doctors. Welcome History, 33, 1–24. 8. Owens, D. C. (2017). The birth of American gynecology. In Medical Bondage: Race, Gender, and the Origins of American Gynecology, pp. 15–41. University of Georgia Press. 9. Richardson, V. M. (2025, September 30). Invisible black women: Medical bias and the silencing of enslaved black women in 18th- and 19th-century British West Indian medical discourse. The Yale Journal of Biology and Medicine, 98(3), 273–283. https://doi.org/10.59249/PVVB2237 10. Molloy, M. S. (2021). “An illicit and criminal intercourse”: Adultery and marital breakdown in the slaveholding South. American Nineteenth Century History, 22(3), 253–269. https://doi.org/10.1080/14664658.2021.2022578
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11. Bailey, M. (2017, May). The Flexner Report: Standardizing medical students through region-, gender-, and race-based hierarchies. American Journal of Law & Medicine, 43(2-3), 209–223. https://doi.org/10.1177/0098858817723660 12. Hernandez-Green, N., Davis, M. V., Farinu, O., Hernandez-Spalding, K., Lewis, K., Beshara, M. S., . . . Chandler, R. (2024, Jan-Dec). Using mHealth to reduce disparities in Black maternal health: Perspectives from Black rural postpartum mothers. Women’s Health (London, England), 20, 17455057241239769. https://doi.org/10.1177/17455057241239769 13. Barnett, K. S., Banks, A. R., Morton, T., Sander, C., Stapleton, M., & Chisolm, D. J. (2022, Jan-Dec). “I just want us to be heard”: A qualitative study of perinatal experiences among women of color. Women’s Health (London, England), 18, 17455057221123439. https://doi.org/10.1177/17455057221123439 14. Montalmant, K. E., & Ettinger, A. K. (2024, December). The racial disparities in maternal mortality and impact of structural racism and implicit racial bias on pregnant black women: A review of the literature. Journal of Racial and Ethnic Health Disparities, 11(6), 3658–3677. https://doi.org/10.1007/s40615-023-01816-x 15. Chambers, B. D., Taylor, B., Nelson, T., Harrison, J., Bell, A., O’Leary, A., . . . McLemore, M. R. (2022, May 4). Clinicians’ perspectives on racism and black women’s maternal health. Women’s Health Reports (New Rochelle, N.Y.), 3(1), 476–482. https://doi.org/10.1089/whr.2021.0148 16. Ajluni, V., & Michalopoulou, G. (2025, January 24). Addressing the underrepresentation of African American mental health professionals: A call to action. Journal of Patient Experience, 12, 23743735241307382. https://doi.org/10.1177/23743735241307382 17. Polan, R. M., Rosen, D. Y., Corey, L. S., & Gogoi, R. P. (2024). Racial and gender disparities in obstetrics and gynecology applicants and professionals. Journal of Clinical Gynecology and Obstetrics, 13(3), 75–82. https://doi.org/10.14740/jcgo997 18. Okoro, O.N., Hillman, L.A., Cernasev, A. (2020). “We get double slammed!”: Healthcare experiences of perceived discrimination among low-income African-American women. Womens Health (Lond), 16 19. Collins, C., Bai, R., Brown, P., Bronson, C. L., & Farmer, C. (2023, January). Black women’s experiences with professional accompaniment at prenatal appointments. Ethnicity & Health, 28(1), 61–77. https://doi.org/10.1080/13557858.2022.2027880 20. Hunte, R., Klawetter, S., & Paul, S. (2022, April). “Black nurses in the home is working”: Advocacy, naming, and processing racism to improve black maternal and infant health. Maternal and Child Health Journal, 26(4), 933–940. https://doi.org/10.1007/s10995-021-03283-4
YOU PLAY A VITAL ROLE IN CHILDREN’S MENTAL HEALTH —
BUT YOU DON’T HAVE TO DO IT ALONE. WE HELP YOU HELP THEM. Providers are on the front lines of behavioral health care: WHO: Pediatricians, family physicians, nurse practitioners, physician assistants, and OB-GYNs serving patients 21 and under. CHALLENGE: Many providers feel unequipped to diagnose, treat, or manage behavioral health conditions. DCPAP equips providers with expert guidance, training, and resources to navigate behavioral health challenges with confidence: • Immediate access to a child and adolescent psychiatrist during office hours: Tuesdays and Thursdays, 12–2 p.m. • Consultations within 24 hours for screening, diagnosis, and treatment.
COMMON TOPICS FOR DCPAP CONSULTATIONS:
• Ongoing training and education through live and recorded webinars, clinical guidelines, and more.
• ADHD, anxiety, depression, and other mental health concerns
• Referral assistance to connect patients with specialized care.
• Medication management and treatment considerations
Timely behavioral health support is critical: · DCPAP’s provider-to-provider collaboration model connects you with child and adolescent psychiatrists for expert guidance. · With timely support, you can confidently address behavioral health concerns, improving patient outcomes.
• Disruptive behavioral problems
FOR PATIENTS 21 AND UNDER.
Visit DEThrives.com/DCPAP. Call 302-513-0929, M–F, 8 AM–5 PM. DCPAP is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $2,912,437 with 20% financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.
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Obstetric Triage as a Gateway to Social Care: Social Needs, Disparities, and Implications for Advancing Equity Alicia L. Salvatore, Dr.P.H., M.P.H. Master of Social Work Program, College of Education and Human Development, University of Delaware; Institute for Research on Equity and Community Health (iREACH), ChristianaCare Michelle Axe, M.S., C.H.E.S. Institute for Research on Equity and Community Health (iREACH); Office of Health Equity, ChristianaCare Mathew K. Hoffman, M.D., M.P.H., F.A.C.O.G. Department of Obstetrics and Gynecology, ChristianaCare
ABSTRACT Objectives: To estimate the prevalence and distribution of social needs among obstetric triage patients at ChristianaCare; examine associations with patient characteristics and insurance status; and identify implementation and policy implications for integrating social determinants of health (SDOH) screening into obstetric care in Delaware. Methods: We conducted cross-sectional SDOH screening among patients aged ≥18 years presenting to the obstetric triage unit at Christiana Hospital (November 2019–February 2020). An 11-item tool covering 10 social-need domains was administered; 326 (82%) patients participated, and 317 unique patients were analyzed. Descriptive statistics estimated social-need prevalence. Age-adjusted logistic regression assessed associations of race/ethnicity and insurance (Medicaid/self-pay vs other) with each domain and with cumulative needs. Screeners completed brief debriefs on feasibility and workflow. Results: Participants had a mean age of 30.2 years; 49.5% were White, 38.4% Black, and 10.7% Hispanic/Latine; 39.1% had Medicaid or were self-pay. Overall, 46.1% reported ≥1 social need and 7.0% reported ≥4 needs. Financial strain, food insecurity, and housing and transportation challenges were among the most frequently endorsed domains. Black and Hispanic/Latine patients and those with Medicaid or self-pay coverage experienced significantly higher odds of multiple socialneed domains and ≥4 needs (all p<0.05). Screening was feasible and acceptable but required attention to privacy, timing, and referral pathways. Conclusions: Nearly half of obstetric triage patients reported unmet social needs, with marked inequities by race/ethnicity and insurance. Triage-based SDOH screening is feasible and can connect patients to social, legal, and community supports. Public Health and Policy Implications: Integrating SDOH and food insecurity screening into obstetric triage, linking patients to social, legal, and Food is Medicine supports, and advancing upstream policies on wages, housing, and racism may narrow racial and socioeconomic gaps in maternal and infant outcomes and advance reproductive justice in Delaware.
INTRODUCTION Maternal morbidity and mortality and adverse infant outcomes remain major public health challenges in the United States, with persistent and unacceptable racial and ethnic inequities.1–5 Black and other patients of color and their infants experience disproportionately high rates of preterm birth, low birth weight, and mortality, even after accounting for individual clinical risk factors and health care use.1–5 These patterns reflect not only clinical risk, but also longstanding social, economic, and structural inequities that shape exposure to stress, resources, and care across the life course.2–5 A large and growing body of public health and social epidemiology research demonstrates that adverse social determinants of health (SDOH)--including low income, food and housing insecurity, neighborhood deprivation, discrimination and racism, and limited access to high-quality care--are major drivers of maternal and infant morbidity and mortality.1,2,5 Life-course and “weathering” perspectives emphasize that poverty, structural racism, and related stressors accumulate over time, producing 24 Delaware Journal of Public Health - December 2025
earlier onset of chronic disease and sustaining inequities in birth outcomes across generations.2–4 Empirical studies have linked socioeconomic disadvantage and structural racism to higher risks of preterm birth, low birth weight, and maternal morbidity.1,5 Health systems have increasingly sought to respond to these upstream drivers by integrating SDOH screening and social care interventions into clinical practice.1,6 In many settings, standardized tools are used to assess domains such as food security, housing stability, transportation, and financial strain, and patients who screen positive are linked to in-house social workers, community health workers, legal partners, and community-based organizations.1,6–9 Early evidence suggests that well-designed social care interventions can improve some health and utilization outcomes, although the evidence base remains heterogeneous and evolving.10,11 Professional organizations have underscored the importance of this work for maternity care. The American College of Obstetricians and Gynecologists (ACOG) highlights SDOH and cultural awareness as core components of reproductive health care and recommends that prenatal care include assessment Doi: 10.32481/djph.2025.12.05
of social and structural drivers of health with linkage to appropriate services when needs are identified.12 ACOG has also issued guidance on hospital-based triage of obstetric patients, emphasizing standardized acuity assessment to ensure timely and safe care.13 Together, these recommendations position pregnancy and the perinatal period as critical windows for identifying and addressing social needs.
regional health system in the Mid-Atlantic. We (1) describe the prevalence and types of social needs among obstetric triage patients; (2) examine associations of social needs with race/ethnicity and insurance status; and (3) summarize implementation lessons and policy implications, with a focus on how obstetric triage can function as a gateway to social care and upstream equity-focused interventions in Delaware.
In Delaware, these national concerns are highly salient. The state’s preterm birth and infant mortality rates remain above national benchmarks, with pronounced racial and geographic inequities.14,15 State reports document persistent disparities in preterm birth, low birth weight, and infant mortality, with Black infants experiencing substantially higher mortality than White infants and adverse outcomes clustering in communities with concentrated social and economic disadvantage such as Wilmington.14–17 Delaware has invested in several initiatives to respond, including the Healthy Women, Healthy Babies (HWHB) program, which provides enhanced preconception, prenatal, and interconception care and bundled clinical and social services for women at highest risk of poor birth outcomes, and Healthy Communities Delaware, which supports community-driven investments in housing, transportation, and other “vital conditions” in high-vulnerability neighborhoods.18–20 These initiatives reflect a growing recognition that improving maternal and infant outcomes requires addressing both individual clinical risks and the social and structural context in which patients live.1–5
METHODS
At the same time, important gaps remain in how SDOH are assessed and addressed in maternity care workflows. Most reported SDOH screening efforts in pregnancy have occurred in outpatient prenatal clinics and high-risk perinatal programs, where brief tools are often acceptable to patients but screening remains inconsistent and implementation uneven.1,6–8,21 In contrast, the obstetric triage literature has focused primarily on clinical acuity tools—such as the Maternal Fetal Triage Index and other obstetric triage scales—and, more recently, on associations between neighborhood-level social vulnerability and triage acuity and other obstetric outcomes.22–25 Acuity assessment refers to assigning an urgency level to each patient at presentation, based on maternal and fetal status, so that those with the most pressing needs are evaluated and treated first.13,22,23 Studies linking triage acuity with the Centers for Disease Control and Prevention’s Social Vulnerability Index (SVI) underscore how communitylevel disadvantage shapes who presents to triage and with what level of urgency, but they do not directly assess patients’ individual social needs or incorporate routine SDOH screening into triage workflows.24,25 Obstetric triage is a high-volume point of unscheduled care and often serves as the de facto entry point into the health system for pregnant patients with limited or late prenatal care. Yet, to our knowledge, no prior U.S. studies have reported routine, patientlevel SDOH or social needs screening conducted specifically in obstetric triage or obstetric emergency units. This leaves a critical evidence gap in understanding how triage could be leveraged to identify unmet social needs, inform care planning, and advance maternal health equity—particularly in states like Delaware, where maternal and infant health inequities are substantial and where state and health-system partners are actively investing in SDOH-focused strategies.14–20 In this study, we report findings from an SDOH screening initiative in an obstetric triage unit at ChristianaCare, a large
Setting This study was conducted in the obstetric triage unit at Christiana Hospital, part of ChristianaCare, a large private, non-profit, academic health system headquartered in Wilmington, Delaware. Christiana Hospital is the state’s largest maternity center and a regional referral hospital serving patients from Delaware and parts of Pennsylvania, New Jersey, and Maryland. The obstetric triage unit is adjacent to the labor and delivery unit and provides unscheduled assessment and care for pregnant and postpartum patients presenting with concerns such as labor, decreased fetal movement, bleeding, pain, and other obstetric complaints. Patients are evaluated by obstetric nurses and providers, who assign triage acuity and determine the need for further evaluation, admission, or discharge with follow-up.13,22,23
Development of the Screening Tool The screening tool used in this study was developed as part of a larger effort to create and test an SDOH screening protocol for the health system. The tool was collaboratively developed by a working group comprised of leaders from the Office of Health Equity, researchers from the system’s embedded research institute (then the Value Institute, now iREACH), and clinical and social work leads from high-need patient programs. Over several months, the group met to establish a vision for social needs screening, identify key domains, review existing instruments, and select questions for each domain. We reviewed items from validated and widely used screening tools, including the Accountable Health Communities Health-Related Social Needs (AHC-HRSN) screener,22 the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE),23 and the Health Leads social needs screening toolkit.24 Given concerns about adding length to workflow, the working group aimed for a relatively short tool and prioritized actionable domains not already captured in other assessments. The final instrument included 11 items measuring ten social need domains: (1) financial insecurity, (2) utility needs, (3) housing quality issues, (4) housing insecurity, (5) food insecurity, (6) transportation needs, (7) interpersonal safety concerns, (8) limited health care access due to cost, (9) health literacy concerns, and (10) urgent needs (see Appendix). Before rollout, the working group decided to conduct screening studies in priority patient areas to inform planning and resource allocation. The first of these was conducted in ChristianaCare’s obstetric triage unit.
Data Collection The screening study was conducted from November 2019 through February 2020. All data collection procedures were developed collaboratively with obstetric triage leadership, nurse managers, and frontline staff. The research coordinator shadowed and observed triage nurses, admissions staff, and medical assistants to identify appropriate screening times, ways to introduce the study, and feasible workflows. The ChristianaCare Institutional Review 25
Board approved the study. Six researchers were trained on study procedures and tools. Recruitment and data collection took place in obstetric triage Monday through Friday from 12:00 pm to 9:00 pm. Multiple communications about the study were sent to triage staff, and a binder with study specifics and contacts was placed at the charge nurse’s station. All patients aged 18 years or older who spoke English or Spanish were eligible to participate. Patients were excluded if a provider indicated that the patient was not fit to approach, if the patient was clinically unstable or required immediate emergency intervention, or if non-medical individuals (e.g., family members or friends) in the room would not leave when privacy was needed to complete the screener. Screeners reviewed patient charts to assess eligibility and approached all eligible patients present during their shifts, typically after the patient had been seen by a provider. This was therefore a convenience sample of patients presenting during staffed hours; no additional sampling or weighting was applied. Screeners introduced themselves, described the study, confirmed eligibility, and obtained verbal consent from interested patients. Sociodemographic and screening questions were administered by interview in English or Spanish, and responses were entered into REDCap, a secure, web-based application for data capture in clinical and translational research.26 Although study materials were translated into Spanish, only one researcher was able to conduct interviews in Spanish and interpretation services were not available for the research; consequently, relatively few Spanish-speaking patients were enrolled. At the end of each shift, screeners completed a brief debrief survey documenting any challenges or successes associated with that day’s screening. The form included checkboxes and open-ended questions about perceived facilitators and barriers (e.g., patient acuity, time constraints, presence of visitors, language needs), patients’ reactions to the questions, perceived safety concerns, and suggestions for improving the process. Debrief responses were reviewed iteratively and coded for recurrent themes related to feasibility, acceptability, and workflow barriers. All participants received a $25 gift card and a bilingual information card about the United Way 211 assistance line. Screeners notified the charge nurse whenever a patient screened positive for interpersonal safety concerns or indicated an urgent need so that appropriate support and/or intervention could be provided.
Measures The study questionnaire included items to assess sociodemographic characteristics and SDOH. Standardized questions were used to assess age (via date of birth), preferred language, and gender. Patients’ primary insurance type was obtained from the electronic health record and classified for analysis as Medicaid/self-pay versus other insurance. Eleven SDOH screening questions measuring 10 domains were administered (Appendix). Questions addressing financial insecurity, utility needs, housing quality issues, and housing insecurity came from the AHC-HRSN screener.22 Patients who reported one or more housing quality issues were classified as having housing quality problems. Food insecurity was assessed using the two-item Hunger Vital Sign; patients who responded affirmatively to either item were considered food insecure.25 Health literacy concerns were measured using a single AHC26 Delaware Journal of Public Health - December 2025
HRSN item asking how often patients needed help reading hospital materials; those who responded “often” or “always” were categorized as having health literacy concerns.22 Items from PRAPARE were used to assess transportation needs and interpersonal safety; patients who reported transportation problems or responded “no” to the interpersonal safety question were classified as having those respective needs.23 Limited health care access due to cost and urgent needs were assessed using items from the Health Leads screening tool.24
Data Analysis We used descriptive statistics to characterize the sample and estimate the prevalence of each social-need domain. All SDOH items were coded as binary variables (yes/no), and we examined the distribution of the total number of domains endorsed (0, 1, 2, 3, 4, 5, 6, 7, 8–10). For regression analyses, we created a dichotomous indicator of cumulative social needs (≥4 vs 0–3) to capture concentrated social risk. To assess associations between patient characteristics and social needs, we fit separate ageadjusted logistic regression models with each SDOH domain (yes/no) as the dependent variable and race/ethnicity (nonHispanic White [reference], non-Hispanic African American/ Black, Hispanic/Latine) or insurance type (Medicaid/self-pay vs other) as the main independent variable. We also modeled the cumulative social-needs indicator (≥4 vs 0–3) as a binary outcome. Analyses used available-case data; participants with missing values for a given variable were excluded from analyses involving that variable. A p-value <0.05 was considered statistically significant. All analyses were conducted using Stata (Version 17.0, StataCorp, College Station, Texas).
RESULTS Participation Rate and Participant Characteristics Eighty-two percent of patients approached agreed to participate. Of the 326 patients who completed the screening, nine were determined to be duplicate visits. For patients with multiple screenings, only the first screen was retained, resulting in a final analytic sample of 317 unique patients. Sociodemographic characteristics of the 317 participants are shown in Table 1. Participants were primarily non-Hispanic White (45.4%) and non-Hispanic African American/Black (38.4%); 10.8% identified as Hispanic/Latine (White, Black, or other). Most participants identified as female (98.7%), and nearly all reported English as their preferred language (99.7%). The majority had commercial insurance (59.6%) or Medicaid (37.2%), and almost all were Delaware residents (90.2%).
Social Determinants of Health Table 2 presents participants’ responses to the 11 SDOH screening items. Table 3 summarizes the prevalence of positive screens by domain and age-adjusted ORs (95% CI) by race/ethnicity and insurance type. Overall, 46.1% of patients reported at least one social need. The most frequently endorsed domains were financial insecurity (25.2%) and food insecurity (21.8%). Similar proportions of participants reported worrying that food would run out before they had money to buy more and that food had run out without money to buy more (17.0% and 17.4%, respectively). Housing quality issues were also common: 13.6% reported one or more housing quality problems, and 4.1% reported two or more. The most frequently reported housing quality issues were pests (4.1%) and water leaks (3.8%). Other
Table 1. Sociodemographic Characteristics of Patients Screened (N=317) % or Mean
n or SD
30.2
7.1
18-24
23.3
25-34 35-44
Age, years
% or Mean
n or SD
Financial insecurity
25.2
80
74
Housing quality issues
13.6
43
56.8
180
Utility needs
6.9
22
16.7
53
Housing insecurity
8.2
26
10
Food insecurity
21.8
69
Transportation needs
10.7
34
Age categories, years
45 and older
Table 2. Social Determinants of Health Needs Reported by Patients who Endorsed Screening Items (N=317)
3.2
Gender Female
98.7
313
Interpersonal safety concerns
0.6
2
Male
1.3
4
Limited health care access due to cost
9.2
29
English
99.7
316
Health literacy concerns
10.8
34
Spanish
0.3
1
Urgent Need(s)
3.2
10
1.0
1.4
0
53.9
171
Preferred language
Race American Indian or Alaska Native
0.3
1
Asian
3.8
12
Black or African American
38.4
125
White
49.5
157
Other
6.6
21
Hispanic or Latine
10.7
34
Non-Hispanic or Latine
89
282
Non-Hispanic White
45.4
144
Hispanic White
4.1
13
Non-Hispanic Black
38.2
121
Hispanic Black
1.3
4
Non-Hispanic Other
5.4
17
Hispanic Other
5.4
17
Medicaid
37.2
118
Medicare
1.3
4
Private
59.6
189
Self-pay
1.9
6
Ethnicity
Race/Ethnicity
Insurance Type
Note. 1 person declined to report Race, Ethnicity, and Race. Age ranged from 18.0 to 73.4 years.
commonly endorsed domains included transportation needs (10.7%), health literacy concerns (10.8%), limited health care access due to cost (9.2%), and housing insecurity (8.2%). Among those with housing insecurity, 3.8% were currently homeless and 4.4% had a steady place to live but were worried about losing it. Fewer participants screened positive for utility needs (6.9%), urgent needs requiring immediate assistance (3.2%), or interpersonal safety concerns (0.6%). Overall, 39.1% of patients reported 1–3 social needs and 7.0% reported four or more. Among those who reported at least one social need, nearly one in six (15%) reported four or more distinct social needs, indicating substantial clustering of social risk in a subset of patients.
Number of SDOH endorsed (Mean + SD) Number of SDOH endorsed
1
18.0
57
2
14.2
45
3
6.9
22
4
4.1
13
5
1.6
5
6
1.0
3
7
0.3
1
8 – 10
0.0
0
Note. 46.1% had one or more SDOH needs.
Associations Between Patient Characteristics and SDOH Social needs clustered by race/ethnicity and insurance status (Table 3). Compared with non-Hispanic White patients, Hispanic/Latine patients had significantly higher odds of food insecurity (OR=2.90, 95% CI 1.38–6.10) and low health literacy (OR=3.04, 95% CI 1.25–7.40). African American/Black patients had higher odds of financial insecurity (OR=1.98, 95% CI 1.15–3.41), utility needs (OR=3.17, 95% CI 1.18–8.52), and housing insecurity (OR=4.51, 95% CI 1.74–11.67), and were more than twice as likely to report more than three social needs (OR=2.63, 95% CI 1.28–5.41; all p<0.05). Patients with Medicaid or self-pay coverage had significantly higher odds of nearly all social-need domains with Medicaid estimates (all except urgent needs), including food insecurity (OR=2.69, 95% CI 1.56–4.65), housing insecurity (OR=10.19, 95% CI 3.42–30.38), and low health literacy (OR=3.25, 95% CI 1.54–6.84), as well as approximately four-fold higher odds of having more than three social needs (OR=4.08, 95% CI 2.06–8.07; all p<0.05). Together, these patterns highlight pronounced inequities in the burden of social needs among obstetric triage patients, particularly along lines of race, ethnicity, and insurance coverage. 27
Table 3. Associations between Patient Characteristics and Social Determinants of Health Needs Reported
Age
Hispanic/Latinx
White
African American/Black
Medicaid or self-pay
Other
OR
(95% CI)
OR
(95% CI)
OR
(95% CI)
OR
(95% CI)
OR
(95% CI)
OR
(95% CI)
Financial insecurity
0.98
(0.94, 1.01)
1.50
(0.69, 3.2)
Ref
-
1.98*
(1.15, 3.41)
1.20
(0.50, 2.91)
2.24**
(1.34, 3.75)
Housing quality issues
0.99
(0.95, 1.04)
1.78
(0.72, 4.4)
Ref
-
1.91
(0.94, 2.89)
2.37
(0.88, 6.33)
1.97*
(1.03, 3.76)
Utility needs
1.03
(0.98, 1.08)
0.38
(0.05, 2.90)
Ref
-
3.17*
(1.18, 8.52)
1.50
(0.30, 7.89)
4.62**
(1.75, 12.15)
Housing insecurity
0.94
(0.88, 1.01)
-
-
Ref
-
4.51*
(1.74, 11.67)
0.74
(0.09, 6.35)
10.19***
(3.42, 30.38)
Food insecurity
0.95*
(0.91, 0.99)
2.9**
(1.38, 6.10)
Ref
-
1.46
(0.82, 2.58)
1.53
(0.65, 3.61)
2.69***
(1.56, 4.65)
Transportation needs
0.95
(0.89, 1.00)
1.51
(054, 4.20)
Ref
-
1.77
(0.81, 3.90)
2.50
(0.87, 7.20)
3.78**
(1.76, 8.04)
Interpersonal safety concerns
0.99
(0.81, 1.21)
-
-
Ref
-
1.25
(0.8, 20.32)
-
-
-
-
Limited healthcare access
0.93
(0.87, 1.00)
1.38
(0.45, 4.22)
Ref
-
1.52
(0.68, 3.4)
1.13
(0.30, 4.24)
2.81*
(1.29, 6.17)
Health literacy concerns
0.95
(0.89, 1.01)
3.04*
(1.25, 7.40)
Ref
-
1.29
(0.57, 2.88)
3.28*
(1.24, 8.68)
3.25**
(1.54, 6.84)
Urgent needs
0.88
(0.78, 1.00)
0.92
(0.16, 1.51)
Ref
-
1.59
(0.42, 6.06)
1.13
(0.12, 10.39)
2.4
(0.66, 8.69)
0.36***
(0.23, 0.57)
0.89
(0.49, 1.61)
2.18*
(1.15, 4.13)
4.08***
(2.06, 8.07)
0 social needs
1.03
(1.00, 1.06)
0.49
(0.24, 1.02)
Ref
-
0.46**
(0.28, 0.74)
0.72
(0.34, 1.5)
1 social need
1.01
(0.97, 1.05)
1.47
(0.63, 3.43)
Ref
-
1.00
(0.54, 1.82)
0.74
(0.26, 2.10)
2 social needs
0.96
(0.91, 1.00)
1.05
(0.38, 2.87)
Ref
-
1.96
(1.00, 3.83)
1.10
(0.33, 3.38)
>3 social needs
0.97
(0.92, 1.02)
2.11
(0.89, 5.02)
Ref
-
2.63**
(1.28, 5.41)
2.77*
(1.01, 7.56)
Note. 37.2% of patients (n=118) had Medicaid and 1.9% (n=6) were self-pay. 28 Delaware Journal of Public Health - December 2025
DISCUSSION In this obstetric triage setting, our principal findings were that nearly half of pregnant patients reported at least one unmet social need and that a substantial subset reported multiple, intersecting needs. Financial strain and food insecurity were the most frequently endorsed domains, and many patients also reported housing-related concerns, transportation barriers, and cost-related access problems. We observed pronounced disparities by race/ethnicity and insurance status: Black and Hispanic/ Latine patients and those with Medicaid or self-pay coverage experienced a substantially higher burden of social needs, including greater odds of housing insecurity and cumulative social risk. These findings indicate that patients presenting for unscheduled obstetric care often face significant social and economic challenges that are tightly intertwined with maternal and infant health risk.1,2,5
What This Study Adds This study contributes in three key ways. First, to our knowledge it is the first U.S. report of routine, patient-level SDOH screening conducted specifically in an obstetric triage unit, a high-volume point of unscheduled care. Second, it documents substantial clustering of social needs and pronounced inequities by race/ ethnicity and insurance status among patients seeking triage care, highlighting obstetric triage as a locus of concentrated social risk. Third, it illustrates how triage-based screening can be integrated into a broader health-system and state policy context--using Delaware as a case example--to inform clinical workflows, align with existing social care and Food is Medicine programs, and guide upstream investments in maternal and infant health equity.
Comparison with Prior Literature Our prevalence estimates are consistent with prior work on SDOH screening in prenatal care and high-risk perinatal clinics, which has documented high rates of financial strain, food insecurity, and housing-related concerns among pregnant patients.2,22,27 Some domains in our sample were reported at slightly lower rates than in clinic-based studies, which may reflect differences in patient populations, local social conditions, screening tools, or the acute-care context of obstetric triage. Despite these differences, our findings reinforce that social needs are common among pregnant patients across a range of settings and that addressing these needs is central to advancing maternal health equity.1,2,6 Our study extends existing work by focusing on obstetric triage, a high-volume point of unscheduled care that has rarely been examined as a venue for social needs assessment. Prior triage research has emphasized clinical acuity tools and, more recently, associations between neighborhood-level social vulnerability and triage acuity.22–25 By demonstrating both a substantial burden of social needs and marked inequities in their distribution among triage patients, our findings suggest that obstetric triage is an important, and currently underused, opportunity to identify unmet social needs, inform care planning, and connect patients with resources during pregnancy. Our results are also consistent with broader health services and social epidemiology research demonstrating that social needs are patterned along lines of race, ethnicity, and insurance status in ways that reflect structural racism and economic inequality.1–5
The higher burden of social needs among Black and Hispanic/ Latine patients and those covered by Medicaid or self-pay underscores the importance of centering equity in the design and implementation of SDOH screening and response efforts. This includes not only identifying needs, but also ensuring that screening is linked to meaningful, accessible, and culturally responsive resources and interventions.1,6,28,29
Implementation Lessons Implementing routine social needs screening in obstetric triage yielded several practical lessons. First, patients were more receptive when screeners briefly explained why they were asking about social needs and how the information might be used to improve care and connect them with resources, consistent with prior work highlighting the importance of transparency and trustbuilding in SDOH screening.1,22,28,29 Framing the screener as part of whole-person, family-centered care appeared to normalize the questions and reduce concerns about judgment or negative consequences. Second, maintaining adequate privacy was essential yet challenging in a busy triage environment. Visitors were often present in the room, and screeners sometimes deferred or modified questions about interpersonal safety and urgent needs when privacy could not be ensured. These experiences highlight the importance of explicit workflows for securing privacy--such as standardized scripts for asking visitors to step out--when integrating SDOH screening into acute-care settings. Third, successful implementation depended on clear roles and strong clinical champions. Support from triage charge nurses, attending obstetricians, and social workers helped integrate screening into routine processes, troubleshoot barriers (e.g., timing relative to clinical evaluation), and promote staff buyin. Screeners emphasized the value of having straightforward responses to positive screens, such as simple “next step” pathways, standardized social work consults for higher-risk needs, and widely distributed 211 cards or resource lists that could be provided even when a full social work assessment was not feasible. The debrief process itself—inviting staff to reflect on what worked, what felt uncomfortable, and what might be improved—functioned as a low-cost quality improvement strategy and reinforced shared ownership of the screening initiative. From a public health perspective, these findings suggest that obstetric triage is a critical touchpoint for identifying unmet social needs among pregnant patients in Delaware and the surrounding region. Nearly half of triage patients in this study reported at least one social need, with a disproportionate burden among Black and Hispanic/Latine patients and those with Medicaid or self-pay coverage. Leveraging triage as an opportunity for social needs assessment could help health systems and public health agencies identify individuals and communities facing concentrated social disadvantage and strengthen linkages to community-based supports.
Strengths This study has several strengths. It focuses on an obstetric triage setting--a high-volume point of unscheduled care that has been largely overlooked in prior work on social needs and pregnancy. By integrating screening into routine triage workflow, we were able to engage patients who may have limited or inconsistent 29
contact with prenatal care and who may therefore be at particular risk for unmet social needs. The screening tool drew on items from widely used, evidence-informed instruments and covered multiple domains, allowing us to characterize both specific needs (e.g., food insecurity, housing quality) and cumulative social risk.7–9,27 The study included a racially and ethnically diverse sample with substantial Medicaid coverage, enhancing the relevance of the findings for populations disproportionately affected by adverse maternal outcomes and structural inequities.14–17 Finally, pairing quantitative screening data with debriefing from screeners provided complementary insights about feasibility, acceptability, and workflow challenges.
Limitations Several limitations should be considered. This was a single-site study in one obstetric triage unit within a large health system, which may limit generalizability to other hospitals, geographic areas, or models of obstetric care. Recruitment occurred only during specific weekday hours; patients presenting overnight or on weekends were not systematically screened, and their social needs may differ from those captured in this sample. We excluded patients who were clinically unstable or required immediate emergency intervention, and screeners occasionally deferred or abbreviated the screener when privacy or safety concerns arose. As a result, our estimates may understate the true prevalence of social needs among all triage patients. Social needs were measured using self-report, which is subject to social desirability bias and under-reporting, particularly for sensitive domains such as interpersonal safety and urgent needs. Concerns about child welfare involvement, immigration status, or stigma may have led some patients to withhold information even when confidentiality was emphasized. In addition, the 18% of eligible patients who declined participation may have had different social-needs profiles than participants; if those with the greatest social and economic adversity were less likely to participate, our findings may be conservative. Finally, we relied on cross-sectional data collected at a single encounter and adjusted for a limited set of sociodemographic variables, so we cannot draw causal inferences about the relationship between social needs and clinical outcomes. Unmeasured factors such as immigration status, language proficiency, and experiences of discrimination may also contribute to the observed disparities.1–5
Public Health and Policy Implications Our finding that nearly half of obstetric triage patients screened positive for at least one social need, with a disproportionate burden among Black and Hispanic/Latine patients and those with Medicaid or self-pay coverage, underscores that social and economic conditions are not peripheral to perinatal care; they are core clinical concerns. The distribution of needs in this study—financial strain, food insecurity, housing problems, transportation barriers, and cost-related access difficulties— reflects both proximate social risks and deeper “fundamental” causes of health inequity, including low wages, racialized labor markets, historic disinvestment in communities of color, and the regional shortage of affordable housing. Simply asking patients about unmet needs without changing these underlying conditions risks placing responsibility for structural failures back onto pregnant people themselves.1–5,9,16,17 30 Delaware Journal of Public Health - December 2025
From a clinical and health-system perspective, obstetric triage is a uniquely high-leverage setting to identify and respond to social needs. Triage is often the first point of contact during pregnancy for patients with limited prenatal care and is already organized around time-sensitive assessment and escalation protocols.13,22,23 Embedding brief, standardized social needs screening into triage workflows—and linking positive screens to warm handoffs, community health workers, or care coordinators—could transform what is currently a reactive encounter into a gateway for more proactive, continuous care.1,6–11,21 Evidence syntheses from the Social Interventions Research and Evaluation Network and others suggest that social care interventions embedded in clinical settings can reduce social risks and improve some health and utilization outcomes, especially when they go beyond screening alone to offer navigation, counseling, and ongoing support.10,11,28 Delaware could strengthen this approach by explicitly incorporating triage-based SDOH screening and response into perinatal quality and safety efforts, adopting a common screener across obstetric triage units, building structured SDOH fields and alerts into the electronic health record, and tracking process and outcome measures stratified by social risk, race/ethnicity, and insurance. Aligning SDOH work with existing safety bundles would reinforce that addressing social risk is part of quality and patient safety rather than an optional add-on. In Delaware, triage-based SDOH screening can be used as a front door to existing maternal and child health initiatives that address social risk and inequity. Healthy Women, Healthy Babies; evidence-based home visiting programs; Medicaidcovered doula services; Healthy Communities Delaware; medical–legal partnerships; and Medicaid managed care social care programs all provide potential downstream pathways for the high-need patients identified in this study.18–20,29–31 Standardized referral protocols from obstetric triage to these programs—supported by embedded community health workers, social workers, or navigators in triage—could help ensure that pregnant patients with multiple or high-risk needs are connected to enhanced clinical, behavioral health, legal, and community supports before discharge. Evaluations of enhanced prenatal and interconception care, nurse home visiting, and doula care suggest that such models can improve perinatal outcomes and reduce disparities, particularly among Medicaid-insured and racially marginalized populations.19,30,31 Medical–legal partnerships, which embed civil legal services into care teams, offer another strategy for addressing healthharming legal needs such as unsafe housing, eviction, utility shutoffs, benefit interruptions, and intimate partner violence; Delaware’s early maternal health MLP pilot and subsequent national work indicate that resolving legal needs during pregnancy may improve maternal and infant outcomes and reduce costs.29,32 Food insecurity was one of the most common needs in our sample, and Delaware is already investing in Food is Medicine models that can be linked to triage findings. The Delaware Food Farmacy model provides medically tailored groceries, nutrition education, and community health worker support for adults with chronic conditions, and the maternal Food Farmacy pilot extends this approach to pregnant patients
through produce prescriptions and pregnancy-focused wraparound supports.33,34 Early evaluations of Food is Medicine programs, including Delaware’s maternal Food Farmacy, point to benefits for food security, diet quality, cardiometabolic outcomes, and perceived dignity and respect, while also highlighting the complexity of implementation and scaling.11,33–35 At the policy level, federal guidance on health-related social needs and section 1115 Medicaid demonstrations have begun to treat medically supportive food and nutrition (e.g., medically tailored meals, food pharmacies, produce prescriptions) as allowable Medicaid supports, including for some pregnant and postpartum individuals.35 In several states, these policies are being operationalized through partnerships between Medicaid managed care plans and community-based Food is Medicine organizations, which provide medically tailored meals and produce prescriptions to pregnant people with nutrition-sensitive conditions and seek to integrate nutrition supports into standard care pathways.34,35 The evidence base for maternal health outcomes is still developing, but early program evaluations and implementation studies underscore both the promise and the complexity of scaling these interventions.34,35 Medicaid coverage and managed-care policy remain powerful tools for advancing both social care and structural equity. Building on Delaware’s Medicaid expansion and extended postpartum coverage, policymakers and health plans could incentivize routine SDOH screening in obstetric settings; reimburse community health workers, doulas, and social workers for navigation and advocacy; integrate Food is Medicine programs—such as the Delaware Food Farmacy for pregnant patients—into covered benefit structures; and incorporate social risk and response measures into quality dashboards.10,11,18–20,28,30,32–35 At the same time, clinic-based interventions must be coupled with upstream policies that address fundamental causes of maternal health inequities: living wages and predictable work schedules; expansion of high-quality, truly affordable housing; anti-racist zoning and lending policies; enforcement of fair housing laws; and investments in transportation, childcare, and digital infrastructure in communities with the greatest social and health vulnerability.1–5,9,16,17
CONCLUSION In summary, obstetric triage-based SDOH screening offers a pragmatic way to identify high-need patients and connect them to evidence-based social care, legal, and Food is Medicine interventions, including those already operating in Delaware. However, the public health impact of these efforts depends on whether they are paired with policies that address the root causes of social and racial inequities—low and unequal wages, unstable housing, and structural racism across institutions. Aligning triage-based screening, Medicaid benefits (including nutrition supports for pregnant people), and broader economic and housing justice policies is essential to improving maternal and infant outcomes and advancing reproductive justice in Delaware. All such efforts should be explicitly designed, implemented, and evaluated with a focus on racial and economic equity to ensure they narrow, rather than inadvertently widen, existing gaps in maternal and infant health.
ACKNOWLEDGEMENTS We thank Jacqueline Ortiz and SDOH Screening Working Group members for their leadership and guidance. We also thank Mia Papas, Tiffany Cannon, Mary Anne Bryant, Kathy Euler, Carrie Kitto, Jennifer Nav, Alex Waad, Franklin Iheanacho, and Kristin Mitchell for their contributions to this study. At the time of the study, Franklin Iheanacho and Kristin Mitchell were scholars with the Harrington Trust Scholars Program; we are grateful to this program (led by Marshala Lee-McCall).
FUNDING AND CONFLICTS OF INTEREST This study did not receive specific external research funding; data collection and analysis were supported by existing institutional resources at ChristianaCare and the University of Delaware. The authors declare no financial or other conflicts of interest related to this work. All study procedures were reviewed and approved by the ChristianaCare Institutional Review Board and conducted in accordance with applicable ethical standards and the Principles of the Ethical Practice of Public Health. Dr. Salvatore may be contacted at asalvato@udel.edu.
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9. Health Leads. (2018). Social needs screening toolkit. Boston (MA): Health Leads. https://healthleadsusa.org/news-resources/the-health-leads-screening-toolkit/ 10. Gottlieb, L. M., Wing, H., & Adler, N. E. (2017, November). A systematic review of interventions on patients’ social and economic needs. American Journal of Preventive Medicine, 53(5), 719–729. https://doi.org/10.1016/j.amepre.2017.05.011 11. Viswanathan, M., Kennedy, S., Eder, M., Webber, E., Bean, S., Cairo, A., . . . Gottlieb, L. (2022). Social needs interventions to improve health outcomes: Review and evidence map. Washington (DC): Patient-Centered Outcomes Research Institute. https://www.pcori.org/sites/default/files/PCORI-Social-NeedsInterventions-to-Improve-Health-Outcomes-Scoping-Review-EvidenceMap-Report.pdf
24. Prasannan, L., Alvarez, A., Shahani, D., & Blitz, M. J. (2025, May 27). Social vulnerability and triage acuity among pregnant people seeking unscheduled hospital care. Journal of Perinatal Medicine, 53(7), 877–884. https://doi.org/10.1515/jpm-2025-0095 25. Agency for Toxic Substances and Disease Registry. (2022). CDC social vulnerability index (SVI). Atlanta (GA): CDC. https://www.atsdr.cdc.gov/placeandhealth/svi/index.html 26. Harris, P. A., Taylor, R., Thielke, R., Payne, J., Gonzalez, N., & Conde, J. G. (2009, April). Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support. Journal of Biomedical Informatics, 42(2), 377–381. https://doi.org/10.1016/j.jbi.2008.08.010
12. Committee on Health Care for Underserved Women. (2018, January). ACOG Committee Opinion No. 729: Importance of social determinants of health and cultural awareness in the delivery of reproductive health care. Obstetrics and Gynecology, 131(1), e43–e48. https://doi.org/10.1097/AOG.0000000000002459
27. Hager, E. R., Quigg, A. M., Black, M. M., Coleman, S. M., Heeren, T., Rose-Jacobs, R., . . . Frank, D. A. (2010, July). Development and validity of a 2-item screen to identify families at risk for food insecurity. Pediatrics, 126(1), e26–e32. https://doi.org/10.1542/peds.2009-3146
13. American College of Obstetricians and Gynecologists. (2016, July). ACOG Committee Opinion No. 667: Hospital-based triage of obstetric patients. Obstetrics and Gynecology, 128(1), e16–e19. https://doi.org/10.1097/AOG.0000000000001524
28. Social Interventions Research and Evaluation Network (SIREN). (2024). Evidence and resource library. University of California, San Francisco. https://sirenetwork.ucsf.edu/tools/evidence-library
14. Kaiser Family Foundation. (2024). Women’s health: Delaware state profile. https://www.kff.org/interactive/womens-health-profiles/delaware/ maternal-infant-health/1441162580/ 15. March of Dimes. (2025). 2025 March of Dimes report card: Delaware. White Plains (NY): March of Dimes; 2025. https://www.marchofdimes.org/peristats/reports/delaware/report-card 16. Delaware Department of Health and Social Services. (2021). Delaware focus: Health inequities and race in the First State. https://udspace.udel.edu/items/8af20ed0-fc3f-4f04-b956-4b8021feebf9 17. Mpasi, P. (2024). Delaware strategies to advance health equity in maternal and infant health. Presentation to the HRSA Advisory Committee on Infant Mortality. https://www.hrsa.gov/sites/default/files/hrsa/advisory-committees/infantmortality/meetings/april-2024-state-approaches-de.pdf 18. Delaware Division of Public Health. (2024). Healthy women, healthy babies (HWHB). Program description. Delaware Thrives https://dethrives.com/programs/healthy-women-healthy-babies 19. Hussaini, K. S., Gardesey, M. D., Yocher, G., & Paul, D. A. (2020, October). Evaluating the Health Outcomes of the Healthy Women Healthy Babies Program in Delaware. Maternal and Child Health Journal, 24(10), 1259–1266. https://doi.org/10.1007/s10995-020-02972-w 20. Phillips, K. D. (2022, August 31). Healthy Communities Delaware: Accelerating place-based efforts to improve the vital conditions for health, well-being and equity. Delaware Journal of Public Health, 8(3), 10–12. https://doi.org/10.32481/djph.2022.08.004 21. Peahl, A. F., Rubin-Miller, L., Paterson, V., Jahnke, H. R., Plough, A., Henrich, N., . . . Shah, N. (2023, January 6). Understanding social needs in pregnancy: Prospective validation of a digital short-form screening tool and patient survey. AJOG Global Reports, 3(1), 100158. https://doi.org/10.1016/j.xagr.2022.100158 22. Ruhl, C., Scheich, B., Onokpise, B., & Bingham, D. (2015, Nov-Dec). Content Validity Testing of the Maternal Fetal Triage Index. J Obstet Gynecol Neonatal Nurs, 44(6), 701–709. https://doi.org/10.1111/1552-6909.12763 23. Smithson, D. S., Twohey, R., Rice, T., Watts, N., Fernandes, C. M., & Gratton, R. J. (2013, October). Implementing an obstetric triage acuity scale: Interrater reliability and patient flow analysis. Am J Obstet Gynaecol, 209(4), 287–293. https://doi.org/10.1016/j.ajog.2013.03.031
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29. Community Legal Aid Society Inc. (2013). Medical-Legal Partnership Pilot Study: Final Report. Delaware Division of Public Health, Wilmington. 30. Kozhimannil, K. B., Hardeman, R. R., Attanasio, L. B., Blauer-Peterson, C., & O’Brien, M. (2013, April). Doula care, birth outcomes, and costs among Medicaid beneficiaries. American Journal of Public Health, 103(4), e113–e121. https://doi.org/10.2105/AJPH.2012.301201 31. Olds, D. L., Henderson, C. R., Jr., Tatelbaum, R., & Chamberlin, R. (1986, January). Improving the delivery of prenatal care and outcomes of pregnancy: A randomized trial of nurse home visitation. Pediatrics, 77(1), 16–28. https://doi.org/10.1542/peds.77.1.16 32. MedStar Health. (2023). Medical-legal partnerships can help improve maternal and infant health outcomes. News release summarizing commentary in Obstet Gynecol. https://www.news-medical.net/news/20231027/Medical-legal-partnershipscan-help-improve-maternal-and-infant-health-outcomes.aspx 33. Axe, M., McCallops, K., Oluwadero, J., & Karpyn, A. (2025, November 24). The Delaware Food Farmacy: Integrating medically tailored groceries and community health workers into chronic disease management. Delaware Journal of Public Health, 11(4), 24–30. https://doi.org/10.32481/djph.2025.11.05 34. Karpyn, A., Eze, V., & Axe, M. (2025, November 24). Integrating Food and Care: Evaluating Impacts of Delaware Food Farmacy, a Food is Medicine Pilot for Maternal Health. Delaware Journal of Public Health, 11(4), 74–83. https://doi.org/10.32481/djph.2025.11.09 35. Food is Medicine Coalition. (2024). Food is Medicine: A state medicaid policy toolkit. Center for Health Law and Policy Innovation of Harvard Law School. Boston (MA): CHLPI. https://www.healthlawlab.org/wp-content/uploads/2024/07/Food-isMedicine-A-State-Medicaid-Policy-Toolkit-2024.pdf
APPENDIX Social Determinants of Health Domains and Screening Items Domain
Screening Item(s)
Financial insecurity
In the past 12 months, have you been worried about, or been unable to pay any type of bills? For example, your heating bill, electric bill, phone bill, cable bill, medical co-pays, prescriptions, etc.? Yes No
Housing quality issues
Think about the place you live. Do you have problems with any of the following? Please tell me all that apply to you. Pests such as bugs, ants, or mice Mold Lead paint or pipes Inadequate heat Oven or stove not working No or not working smoke detectors Water leaks No, do not have any of these problems
Housing insecurity
What is your living situation today? You have a steady place to live You have a place to live today but are worried about losing it in the future You do not have a steady place to live (are temporarily staying with others in a hotel, in a shelter, living outside on the street, on a beach, in a car, abandoned building, bus or train station, or in a park)
Utility needs
In the past 12 months has the electric, gas, oil, or water company threated to shut off or shut off services in your home? Yes No Already shut off
Food insecurity
Within the past 12 months, did you worry that your food would run out before you got money to buy more? Often true Sometimes true Never true Within the past 12 months, did the food you bought just not last and you didn’t have money to get more? Often true Sometimes true Never true
Transportation needs
In the past 12 months, has lack of reliable transportation kept you from medical appointments or getting your medicine, from non-medical meetings, appointments, work or from getting things needed for daily living? Yes No
Interpersonal safety concerns
Do you feel physically and emotionally safe where you currently live? Yes No
Limited health care access due to cost
In the past 12 months, have you needed to see a doctor but could not because of cost? Yes No
Health literacy concerns
How often do you have a problem understanding what is told to you about your medical condition? Never Rarely Sometimes Often Always
Urgent needs
Are any of your needs urgent? For example, you don’t have food tonight or you don’t have a place to sleep tonight. Yes No 33
2025
HEAD START: DELAWARE Head Start is a federal program that includes Head Start Preschool, which serves children ages
ENROLLMENT AT-A-GLANCE
3 to 5, and Early Head Start, which supports infants,
Children Enrolled3
toddlers under age three, pregnant women, and their
Early Head Start: 688
families. Both programs provide comprehensive, highquality services that support early learning, health, nutrition, and family well-being. Children are eligible if their family income is below the federal poverty line ($32,150 for a family of four), they are in foster care, or
Head Start Preschool: 1,175 Total: 1,863 —————————————————————————————————————————————————
they are experiencing homelessness.
Foster Care4
Head Start reflects the needs of each community it
Early Head Start: 22
serves. Federal funds go directly to local grantees who operate programs in rural, urban, and suburban communities in a variety of settings, including centers, family child care, churches, and schools. Each program relies on input from parents and community members to ensure services are tailored and effective. This flexibility also allows programs to draw on other local, state, and federal funding to maximize their reach and impact.
Delaware received $42,424,385 for Head Start and Early Head Start in FY20241 offering services at 33 program sites.2 Head Start’s impact extends beyond the program itself. Many state and local early learning systems are built around Head Start, relying on these grants, paired with other funding sources, to serve children from
Head Start Preschool: 7 Total: 29 ————————————————————————————————————————————————— Experiencing Homelessness5 Early Head Start: 41 Head Start Preschool: 59 Total: 100 —————————————————————————————————————————————————
IDEA* services for developmental delays and special education6 Early Head Start: 90 Head Start Preschool: 135 Total: 225
a variety of backgrounds. In this way, Head Start has
*The Individuals with Disabilities Education Act (IDEA) provides early intervention
become inextricable from child care and preschool
services to preschool aged children. With its robust developmental screenings and
programs in cities and states nationwide.
services to infants and toddlers who have developmental delays and special education requirement to reserve at least 10% of enrollment for children with disabilities, Head Start plays a crucial role in helping children and families access IDEA services.
Head Start provides early learning, health, nutrition, and family wellbeing services for young children. 50 F ST NW SUITE 740, WASHINGTON, DC | 202.730.0943 | FFYF.ORG
34 Delaware Journal of Public Health - December 2025
HEAD START’S IMPACT ON CHILDREN AND FAMILIES Head Start touches many aspects of children’s development and well-being. While enrolled in Head Start, children receive high-quality early learning and care that encourages learning through play and physical activity. Programs also provide healthy meals and snacks, as well as medical, dental, hearing, vision, and behavioral health screenings. Families are engaged as essential partners in their child’s success, and Head Start’s wrap-around services
PROGRAM ENROLLMENT
remove logistical hurdles allowing parents to earn a
BY AGE IN DELAWARE12
living or finish their education. This is particularly true in rural communities, where a lack of child care options, transportation, and other factors often create additional barriers for parents.
Of the families served in Delaware, 1,253 have one or more parents employed, in school, or in job training.7 As a result, Head Start alumni are more
likely to be kindergarten ready, graduate
from high school, and secure stable jobs.8 Head Start families are also more engaged in their children’s learning9 and are more likely to advance their own education.10
UNDER 1
AGE 1
AGE 2
AGE 3
AGE 4
AGE 5
12%
11%
14%
28%
35%
0%
HEAD START’S IMPACT ON COMMUNITIES Head Start has a positive impact on the communities where it operates. In addition to employing Head
Start staff, programs partner with local businesses and schools for everything from purchasing food and supplies to supporting the transition to kindergarten.
BREAKDOWN OF PROVIDER TYPES IN DELAWARE11
In Delaware, Head Start programs: • Employ 529 teachers, family child care providers, and home visitors,13
PROVIDER TYPE
HEAD START PRESCHOOL
EARLY HEAD START
CENTER-BASED
100%
58%
HOME-BASED
0%
42%
FAMLY CHILD CARE
0%
0%
LOCALLY DESIGNED
0%
0%
• Have 23 partnerships to serve children with disabilities14 and • 17 partnerships to support the transition to
kindergarten.15
UNMET NEED Even with the many local, state, and federal partnerships, there are not enough slots to serve all the children who qualify. In Delaware, only 12% of Early Head Start eligible children and 20% of Head Start Preschool eligible children are currently being served.16
Scan or click the QR code for full references and links.
For more information visit FFYF’s interactive Head Start maps or contact FFYF at mail@ffyf.org. 50 F ST NW SUITE 740, WASHINGTON, DC | 202.730.0943 | FFYF.ORG
35
Rethinking Prenatal and Postpartum Exercise Julia Olsen, Ph.D. Delaware State University
ABSTRACT Regular physical activity and structured exercise during pregnancy and postpartum are strongly associated with improved maternal and infant health outcomes; however, confusion persists among clinicians, fitness professionals, and patients regarding the safety, intensity, and appropriate modes of exercise across the perinatal period. The objective of this paper is to synthesize current evidence on aerobic training, resistance training, flexibility and mobility work, and high-intensity training (HIT) to provide clear, practical, and mode-specific recommendations that support safe, enjoyable, and effective movement during pregnancy and postpartum.
INTRODUCTION Across all modalities, research demonstrates that exercise is both safe and beneficial when individualized, symptomguided, and appropriately modified. Aerobic exercise improves cardiometabolic function, regulates gestational weight gain, reduces the risk of gestational diabetes, and supports glucose control without increasing the risk of fetal distress. Resistance training has been shown to reduce musculoskeletal pain, improve functional strength, and support glucose regulation, with emerging evidence suggesting benefits for fetal growth patterns and long-term child development. Recent studies also indicate that properly scaled high-intensity training (HIT)—whether resistancebased or aerobic—can be performed safely by both athletic and recreationally active pregnant individuals, with normal maternal and fetal physiological responses. Common safety considerations across modalities include thermoregulation, hydration, energy availability, symptom monitoring, and awareness of trimester-specific biomechanical changes. Postpartum participation requires additional attention to pelvic floor function, tissue healing, and a structured return-toplay progression. Collaboration between clinicians and qualified exercise professionals enhances safety, increases adherence, and expands access to safe programming. Overall, contemporary evidence supports the inclusion of diverse exercise modes during pregnancy and postpartum. Clear, individualized, and coordinated guidance can empower pregnant and postpartum individuals to participate safely in meaningful physical activity that supports lifelong health.
PHYSICAL ACTIVITY DURING PREGNANCY Physical activity (PA) during pregnancy or postpartum often feels like uncharted or “murky” territory for individuals and their healthcare providers. Yet, a large body of research demonstrates that regular movement confers significant benefits for maternal, fetal, and postpartum health. The American College of Obstetricians and Gynecologists (ACOG) reaffirmed its 2015 Committee Opinion emphasizing that physical activity is safe for most individuals and can be continued throughout all trimesters with appropriate modifications.1 Despite this guidance, many clinicians and patients still lack clarity on what those modifications should entail and how to balance safety with the benefits of staying active. 36 Delaware Journal of Public Health - December 2025
The growing popularity of higher-intensity and resistance-based exercise presents both opportunities and challenges for clinicians. As exercise practices evolve, healthcare professionals must be equipped to provide clear, evidence-based recommendations that empower pregnant and postpartum individuals to remain active. However, physical activity remains under-discussed in prenatal care; in one study, approximately 40% of pregnant individuals reported initiating the conversation themselves because clinicians did not raise the topic.2 Even when guidance is provided, guidance often lacks specificity regarding frequency, intensity, or mode. This commentary summarizes current evidence on perinatal exercise and translates it into practical guidance for clinicians, fitness professionals, and public health practitioners working with pregnant and postpartum individuals.
Current Trends in Guidance Guidance on perinatal exercise must evolve alongside shifts in public health, fitness culture, and scientific evidence. Clinicians play a critical role in helping patients understand how to exercise safely; however, many report barriers such as limited time, insufficient training, and low confidence in prescribing exercise for this population.3 One proposed solution is to refer to an exercise professional. ACOG’s most recent guidance encourages individuals with uncomplicated pregnancies to engage in aerobic and strengthbased exercise three to four days per week (up to daily) at moderate intensity (approximately 60–80% of age-predicted maximal maternal heart rate) for 30–60 minutes per session.1 Recommended exercise includes a combination of multiple modes of exercise. These recommendations reflect a shift toward inclusive, “safe to do” language that promotes autonomy and confidence.4 Shared decision making and health coaching frameworks can further support individualized exercise planning. Clinicians do not need to act as exercise specialists; collaborating with qualified exercise professionals familiar with trimester-specific and postpartum adaptations can help translate medical guidance into practical, personalized programs.
Modes of Perinatal Exercise A growing body of research has investigated the effects of various exercise modes on healthy pregnant populations, often including fetal outcomes. Once approached with caution, exercise is now recognized as a safe and powerful tool for improving maternal and fetal health.4,5 The following sections summarize key evidence, safety considerations, and practical recommendations for the common modes of perinatal exercise. Doi: 10.32481/djph.2025.12.06
PHYSICAL ACTIVITY AND EXERCISE IN GENERAL Benefits and Overview ACOG states that physical activity poses minimal risk and offers meaningful health benefits before, during, and after pregnancy.1 Physical activity includes any movement that increases energy expenditure, while exercise refers to structured training aimed at improving specific physiological systems. In a recent publication, Koschel noted that “The physical and psychological demands of labor mirror that of an athletic endeavor,” reinforcing the value of fitness-based approaches during pregnancy and postpartum recovery.6 A robust body of evidence shows that physical activity and structured exercise reduce excessive maternal weight gain, improve inflammatory profiles, improve lipid profiles, enhance mental health, and reduce common pregnancy-related symptoms such as low-back pain.7–9 Individualized programming that supports consistency is essential.
Safety Pregnancy involves continual anatomical and physiological adaptations that require appropriate exercise modifications. Symptoms such as fatigue, nausea, dizziness, musculoskeletal discomfort, shortness of breath, and balance changes should guide both long-term planning and day-to-day decisions. The pregnant individual’s healthcare and exercise team must distinguish between absolute contraindications (e.g., severe respiratory disorders, placental abruption, vasa previa, severe preeclampsia) and relative contraindications (e.g., mild preeclampsia, placenta previa, preterm premature rupture of membranes).5 Many conditions once considered absolute contraindications have been reclassified, emphasizing the need to stay current with ACOG and professional exercise organization guidelines. Pregnancy increases heat production, skin vasodilation, and sweating.10 Due to cardiovascular adaptations, heart rate alone may be an unreliable measure of intensity during physical activity or exercise.11 Importantly, the historical recommendation to keep a pregnant individual’s heart rate below 140 beats per minute is no longer considered necessary and is not supported by current guidelines. Therefore, rate of perceived exertion or the talk test are preferred monitoring tools. Intensity, duration, and environment should be modified if heat dissipation is compromised or if metabolic demands are elevated such as with gestational diabetes. Remember to modify positions throughout pregnancy and monitor for the need. Many times, pregnant and postpartum individuals are told they will know when or their body will tell them, but athletes sometimes override these messages, so it is important for the professional to continually monitor and offer modifications when signs show the need, especially after the first trimester. Pregnancy is characterized by increased insulin resistance, hepatic glucose output, and maternal fat metabolism during exercise.12 Healthy individuals without diabetes have a low risk of hypoglycemia during aerobic exercise.1 In contrast, those with pregestational diabetes or insulin-treated gestational diabetes may experience exercise-related hypoglycemia and
require individualized monitoring, nutrition strategies, and insulin adjustments. Postpartum, lactation and fluctuating insulin needs can further increase glycemic variability in insulin-treated diabetes.13 As pregnancy progresses, exercise intensity, volume, and mode should be adjusted to account for cardiovascular adaptations, increased ligamentous laxity, shifting center of mass, altered thermoregulation, and changes in venous return.14,15 Postpartum considerations include pelvic floor status, diastasis recti, tissue healing, sleep disruption, breastfeeding-related energy demands, and psychological readiness. Gradual, structured progression reduces risk and supports long-term recovery. A daily readiness assessment may help to protect the individual and ensure individualization with training both during pregnancy and postpartum. Interprofessional communication is also critical. Exercise professionals should monitor symptoms, reinforce safety, and refer out when medical assessment is needed. Warning signs such as vaginal bleeding, painful contractions, chest pain, amniotic fluid leakage, severe headache, dizziness, decreased fetal movement, or new pelvic pressure warrant immediate cessation of any activity and communication with a healthcare provider.
AEROBIC EXERCISE Benefits and Overview Aerobic exercise includes walking, jogging, swimming, and other rhythmic activities that elevate heart rate. Aerobic exercise can help maintain or improve maternal aerobic capacity and reduce the risk of gestational diabetes mellitus by up to 49% in overweight or obese individuals.16,17 Additional research links second- and third-trimester aerobic exercise to improved sleep quality and enhanced maternal–fetal attachment.18 Overall, evidence strongly supports aerobic exercise as beneficial for both mother and baby.
Safety All modes of aerobic exercise can be safe for cleared individuals. Weight-bearing discomfort may increase later in pregnancy due to increased ligamentous laxity; swimming or other non– weight-bearing options may help maintain activity during symptomatic periods. Postpartum return-to-exercise should follow a gradual, symptomguided progression. During labor, the pelvic floor stretches to 250% of its resting length, requiring up to six months to recover; cesarean healing may also require this time.19 Walking is often appropriate in the first 0–2 weeks postpartum, with higher-impact activities such as running typically delayed until approximately 13 weeks with a structured return-to-play protocol—though some individuals resume earlier.19,20
Practical Recommendations For uncomplicated pregnancies, individuals can follow ACOG’s guidance for moderate-intensity activity.1 Choosing modes they enjoy enhances adherence. Progression should be gradual, with attention to emerging symptoms. Non–weight-bearing or lower impact options may be useful on days when fatigue, nausea, or musculoskeletal discomfort is present. Aerobic benefits can be achieved through accumulated short bouts (e.g., 10–15-minute walks), offering flexibility across trimesters. Postpartum it is important to move in a return-to-play structure.6,19,20 37
RESISTANCE TRAINING Benefits and Overview Resistance training during pregnancy provides a wide range of physical and psychological benefits. Evidence shows that resistance exercise can limit excessive gestational weight gain, reduce low back and sciatic pain, lessen fatigue, enhance mental health, improve sleep quality, reduce pelvic pain, increase energy levels, and support glucose regulation—particularly among individuals with gestational diabetes.12,21,22 Pregnant persons who engage in resistance training may also experience increased uterine blood flow and reduced risk of infant macrosomia, childhood metabolic dysfunction, and improved cognitive outcomes in their children.21 Recent investigations and systematic reviews include participants ranging from professional athletes to recreational exercisers and previously sedentary pregnant persons.21,23,24 Measures such as fetal heart rate, placental function, and symptoms of vena cava compression were monitored during deadlift, flat bench press, and incline bench press for both recreational and professional athletes. Fetal heart rate remained within normal range across all lifts; although heart rate increased after deadlift and incline bench press, it did not significantly change following flat bench press.23 These findings support the safety of traditional lifting techniques in appropriately screened individuals. Additional research confirms that experienced lifters can perform heavy resistance training during pregnancy and postpartum without increasing obstetric or neonatal complications. Experienced athletes appear to tolerate heavy loads with fewer adverse responses compared to individuals without prior resistance training experience.24
Safety Although evidence is promising, exercise professionals and healthcare providers should remain attentive to safety considerations and individual responses. Beginning in the second trimester, prone exercises should be avoided, and supine positions should be limited to short durations.21 In the heavyload resistance training study, one recreational athlete (1 of 41 participants; 48 total assessments) experienced transient symptoms of vena cava compression following a supine exercise. Symptoms resolved quickly, and fetal heart rate remained within normal range throughout the session, underscoring the need for individualized monitoring and modification. Pregnant persons also have an increased risk of diastasis recti due to connective tissue laxity and abdominal expansion.25 While diastasis recti cannot be fully prevented, strengthening the anterior abdominal wall and reinforcing optimal posture may reduce severity and support postpartum recovery. Online, lowcost postpartum core rehabilitation programs may offer accessible options for treatment.25,26 During training sessions, coaches and clinicians should monitor for abdominal “coning” or excessive doming. If present, the movement should be modified or stopped, and the focus shifted to core stabilization strategies.
Practical Recommendations When meeting with a pregnant or postpartum client it is important to first complete initial screening for movement safety and resistance training knowledge, focusing first on foundational strength: the individual should move with a neutral spine, with 38 Delaware Journal of Public Health - December 2025
pelvic stability, and proper breathing mechanics before progressing to weighted or heavy lifting loads. For pregnant individuals, because there is need for flexibility with programming, full-body functional movements are important to implement for each day unless symptoms are limited and the individual is an experienced athlete who trains with split days currently. During the postpartum transition it is important to know the limits and return-to-play basics for increasing progression.6,19 Attention to the pelvic floor and core stabilization is important when the individual is medically cleared. The idea of static supine then prone movements to quadruped, and on is important to remember to ensure long-term strength and beneficial outcomes.19 Continually monitoring for fatigue and other symptoms that may interfere with progression, as mentioned above.
HIGH-INTENSITY TRAINING Benefits and Overview High-Intensity Training (HIT) can be a safe and effective exercise mode during pregnancy and postpartum when appropriately individualized. HIT is generally defined as repeated short bouts of high-effort activity interspersed with low-intensity recovery and may incorporate both cardiovascular and resistance-based formats. During pregnancy, intensity must be prescribed relative to the participant’s fitness level, symptoms, and trimester-specific considerations. Growing evidence supports the safety of well-designed HIT protocols during pregnancy. In a resistance-focused study, pregnant individuals in the second and third trimester performed lifting at 70–90% of their 10-repetition maximum with free breathing, as well as 90% 10RM using the Valsalva maneuver. No fetal bradycardia occurred, and umbilical blood flow indices remained within normal limits.27 Similarly, an aerobic HIT study using 1-minute bouts at near-maximal to maximal effort demonstrated normal maternal and fetal responses, with no bradycardia or abnormal umbilical artery metrics.28 Additional work examining mixed-modality HIT protocols found them safe when sessions were individualized and enjoyment was high—factors associated with reduced symptom burden and improved adherence.29 Collectively, this research suggests that HIT may be feasible for pregnant individuals already accustomed to higher-intensity exercise, as well as those transitioning from moderate-intensity training under proper supervision.
Safety The foundational safety considerations for HIT mirror those of aerobic and resistance exercise, but the rapid fluctuations in intensity warrant additional vigilance. High-intensity efforts increase metabolic heat production.10 As mentioned above, pregnant individuals experience altered heat dissipation due to increased metabolic rate and cardiovascular demands; therefore, HIT sessions should prioritize cool environments, hydration, and sufficient recovery intervals. High-intensity work increases carbohydrate utilization.30 Pregnant individuals, especially those with gestational diabetes or insulintreated diabetes, may require individualized glucose monitoring, pre-session carbohydrate intake, or insulin adjustments to reduce the risk of hypoglycemia.
Rapid directional changes, jumping, or unstable surfaces may be less tolerated later in pregnancy due to balance changes and pelvic girdle discomfort.31 Technique, stability, and symptom monitoring should guide exercise selection.
Beyond traditional certifications, there are training programs for perinatal fitness. These educational pathways help bridge the knowledge gap between medical and fitness domains and promote safer, more collaborative care.
Certain HIT movements produce high intra-abdominal pressure. Participants should be monitored for abdominal coning, which may indicate an increased risk for diastasis recti symptoms.25 Modifications and alternative movement patterns should be used as needed.
Equally important is understanding scope of practice. While an exercise professional should be familiar with appropriate modifications for each phase of pregnancy and postpartum recovery, they must also know when to refer back to the healthcare team. Monitoring symptoms, adjusting training as needed, and maintaining open communication with clinicians ensures safety and continuity of care.
As with all forms of exercise during pregnancy, the appearance of warning signs mentioned above require immediate cessation and referral to a healthcare provider.
Practical Recommendations HIT should be reserved for pregnant individuals with an existing foundation of moderate-intensity exercise and those training in this manner preconception. Postpartum, HIT may be reintroduced only after meeting strength, pelvic floor, and impact-readiness benchmarks. Due to pregnancy-related heart rate variability, using RPE and the talk test as discussed above is important. Begin with shorter intervals (15–30 seconds) and longer recovery periods. Progress only when symptom-free and able to maintain stable breathing and core control. Evidence suggests that HIT is safest and most effective when participants choose modalities they enjoy and feel confident performing.29 It is important to not limit this type of training entirely. As pregnancy progresses, modifications may be needed. Modifications may include cycling, rowing, ski-ergometer, bodyweight circuits (or controlled movement resistance training circuits), and sled push/pulls to keep the individual more upright. With the higher impact of HIT, if urinary leakage, heaviness, or pelvic pain occurs, scale intensity, reduce impact, or integrate pelvic floor coordination strategies. Lastly, the exercise professional should encourage longer intrasession rest periods for higher intensity training and emphasize recovery days, particularly in the third trimester or early postpartum when fatigue is elevated.
EXERCISE PROFESSIONAL RECOMMENDATIONS Exercise professionals should possess a foundational understanding of physiology and sound exercise programming, but not all have specialized knowledge in maternal health. While specialized certification is not required to train perinatal clients, ongoing education and professional development are essential. Several reputable credentialing organizations—such as the American College of Sports Medicine (ACSM) and the National Strength and Conditioning Association (NSCA)—require both theoretical knowledge and practical competence to earn certification and are known to be reliable. For prenatal and postpartum individuals, it is important to seek professionals who are confident in applying current evidencebased guidelines and who understand the unique physiological changes that occur throughout pregnancy and recovery. Key aspects of perinatal support include empathy, body image awareness, and an understanding that psychological and emotional wellness may evolve alongside physical changes.
Collaboration between healthcare providers and exercise professionals allows for integration of medical guidance into training design and daily symptom-based adjustments. Beyond pregnancy, exercise professionals should be wellversed in postpartum recovery, including pelvic floor health, diastasis recti management, and progressive return-toexercise protocols.
PRACTICAL APPLICATIONS Ongoing collaboration between clinicians and qualified exercise professionals is essential to support safe participation and longterm adherence. No matter the mode of PA or exercise—and whether the individual is pregnant or postpartum—exercise professionals should prioritize individualized programming that centers enjoyment and symptom-guided progression. Because physiological responses vary widely, using RPE or the talk test is often more reliable than heart-rate targets. Daily monitoring for symptoms and continuous assessment during activity allow the professional to adjust mode, intensity, duration, and technique as needed. Hydration, temperature regulation, and adequate energy intake should be emphasized throughout pregnancy and postpartum. Postpartum individuals benefit from a structured return-to-play progression that accounts for pelvic floor status, tissue healing, and functional readiness.
CONCLUSION Evidence supports the safety and benefits of multiple modes of physical activity and exercise during pregnancy and postpartum. When individualized and symptom-guided, these activities improve maternal cardiometabolic health, functional strength, mental well-being, and fetal outcomes. Collaboration between clinicians and exercise professionals, including clear referral pathways, enhances safety and adherence. Postpartum returnto-exercise should follow a structured progression that accounts for tissue healing, pelvic floor function, and functional readiness. Promoting accessible, enjoyable, and evidence-based physical activity and exercise empowers individuals to maintain lifelong health for both parent and child. Dr. Olsen may be contacted at jolsen@desu.edu.
REFERENCES 1. American College of Obstetricians and Gynecologists. (2020). Physical activity and exercise during pregnancy and the postpartum period. Committee Opinion No. 804. 2. Laudańska-Krzemińska, I., & Krzysztoszek, J. (2024, February 29). Physical activity promotion among pregnancy - the role of physician from the women’s perspective. Frontiers in Public Health, 12, 1335983.
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https://doi.org/10.3389/fpubh.2024.1335983 3. Okafor, U. B., & Goon, D. T. (2021, May 19). Physical activity advice and counselling by healthcare providers: A scoping review. Healthcare (Basel), 9(5), 609. https://doi.org/10.3390/healthcare9050609 4. Davenport, M. H., Ruchat, S.-M., Garcia, A. J., Ali, M. U., Forte, M., Beamish, N., . . . Neil-Sztramko, S. E. (2025). 2023 Canadian guideline for physical activity throughout pregnancy. British Journal of Sports Medicine, 59(8), 515–526. https://doi.org/10.1136/bjsports-2025-109785 5. Mottola, M. F., Davenport, M. H., Ruchat, S. M., Davies, G. A., Poitras, V. J., Gray, C. E., . . . Zehr, L. (2018, November). 2019 Canadian guideline for physical activity throughout pregnancy. British Journal of Sports Medicine, 52(21), 1339–1346. https://doi.org/10.1136/bjsports-2018-100056 6. Koschel, T. L. (2025). Perinatal periodization: Trimester phased training for beginner to elite athletes. Strength and Conditioning Journal, 47(6) 657–677. https://doi.org/10.1519/SSC.0000000000000921 7. Caputo, E. L., Ferreira, P. H., Ferreira, M. L., Bertoldi, A. D., Domingues, M. R., Shirley, D., & Silva, M. C. (2019, October 1). Physical activity before or during pregnancy and low back pain: Data from the 2015 Pelotas (Brazil) birth cohort study. Journal of Physical Activity & Health, 16(10), 886–893. https://doi.org/10.1123/jpah.2018-0624 8. Mizgier, M., Mruczyk, K., Jarząbek-Bielecka, G., & Jeszka, J. (2018). The impact of physical activity during pregnancy on maternal weight and obstetric outcomes. Ginekologia Polska, 89(2), 80–88. https://doi.org/10.5603/GP.a2018.0014 9. Redondo-Delgado, P., Alejandro, S. L., & Sergio, M. I. (2025, September 12). Impact of exercise training during pregnancy on maternal biomarkers: A systematic review. American Journal of Obstetrics and Gynecology, S00029378(25)00675-1; Advance online publication. https://doi.org/10.1016/j.ajog.2025.09.021 10. Filipec, M., & Đurin, M. J. (2025). Thermoregulation and endocrine response during exercise in pregnancy. Physiologia, 5(1), 2. https://doi.org/10.3390/physiologia5010002 11. Pivarnik, J. M. (1996, August). Cardiovascular responses to aerobic exercise during pregnancy and postpartum. Seminars in Perinatology, 20(4), 242–249. https://doi.org/10.1016/S0146-0005(96)80017-6 12. Davenport, M. H., Sobierajski, F., Mottola, M. F., Skow, R. J., Meah, V. L., Poitras, V. J., . . . Ruchat, S. M. (2018, November). Glucose responses to acute and chronic exercise during pregnancy: A systematic review and meta-analysis. British Journal of Sports Medicine, 52(21), 1357–1366. https://doi.org/10.1136/bjsports-2018-099829 13. Donovan, L. E., Bell, R. C., Feig, D. S., Lemieux, P., Murphy, H. R., Sigal, R. J., . . . Yamamoto, J. M. (2024, October). Glycaemic patterns during breastfeeding with postpartum use of closed-loop insulin delivery in women with type 1 diabetes. Diabetologia, 67(10), 2154–2159. https://doi.org/10.1007/s00125-024-06227-z 14. Gangakhedkar, G. R., & Kulkarni, A. P. (2022). Physiological changes in pregnancy. Indian Journal of Critical Care Medicine : Peer-Reviewed, Official Publication of Indian Society of Critical Care Medicine, 25(Suppl 3), S189–S192. https://doi.org/10.5005/jp-journals-10071-24039 15. Troiano, N. H. (2018, Fall). Physiologic and hemodynamic changes during pregnancy. AACN Advanced Critical Care, 29(3), 273–283. https://doi.org/10.4037/aacnacc2018911 16. Kramer, M. S., & McDonald, S. W. (2006, July 19). Aerobic exercise for women during pregnancy. Cochrane Database Syst Rev, 2006(3), CD000180. 17. Pascual-Morena, C., Cavero-Redondo, I., Álvarez-Bueno, C., Lucerón-LucasTorres, M., Sanabria-Martínez, G., Poyatos-León, R., . . . Martínez-Vizcaíno, V. (2021, August 7). Exercise versus metformin to improve pregnancy outcomes among overweight pregnant women: A systematic review and network metaanalysis. Journal of Clinical Medicine, 10(16), 3490. https://doi.org/10.3390/jcm10163490 18. Shen, W. C., & Chen, C. H. (2021, March). Effects of non-supervised aerobic exercise on sleep quality and maternal-fetal attachment in pregnant women: A randomized controlled trial. Complementary Therapies in Medicine, 57, 102671. https://doi.org/10.1016/j.ctim.2021.102671
40 Delaware Journal of Public Health - December 2025
19. Selman, R., Early, K., Battles, B., Seidenburg, M., Wendel, E., & Westerlund, S. (2022, October 1). Maximizing recovery in the postpartum period: A timeline for rehabilitation from pregnancy through return to sport. International Journal of Sports Physical Therapy, 17(6), 1170–1183. https://doi.org/10.26603/001c.37863 20. Benoît, K., St-Laurent, A., Babineau, V., & Ruchat, S. M. (2025, January 1). A descriptive study of the timing and type of physical activity that is being resumed in early postpartum. Appl Physiol Nutr Metab, 50, 1–10. https://doi.org/10.1139/apnm-2024-0283 21. Duchette, C., Perera, M., Arnett, S., White, E., Belcher, E., & Tinius, R. (2024, June 19). Benefits of resistance training during pregnancy for maternal and fetal health: A brief overview. International Journal of Women’s Health, 16, 1137–1147. https://doi.org/10.2147/IJWH.S462591 22. Redondo-Delgado, P., Blanco-Giménez, P., López-Ortiz, S., García-Chico, C., Vicente-Mampel, J., & Maroto-Izquierdo, S. (2025, July). Effects of strength training on quality of life in pregnant women: A systematic review. Acta Obstetricia et Gynecologica Scandinavica, 104(7), 1231–1243. https://doi.org/10.1111/aogs.15122 23. Dalhaug, E. M., Sanda, B., Bø, K., Brown, W., & Haakstad, L. A. H. (2025, September 2). Pushing limits: The acute effects of a heavy-load resistance protocol and supine exercise on fetal well-being. BMJ Open Sport & Exercise Medicine, 11(3), e002639. https://doi.org/10.1136/bmjsem-2025-002639 24. Mathisen, T. F., Hubin, A., Mountjoy, M., & Sundgot-Borgen, J. (2025). Safety of heavy resistance exercise during pregnancy and postpartum: A controlled, prospective cohort study. Women in Sport and Physical Activity Journal, 33(1) 25. Gruszczyńska, D., & Truszczyńska-Baszak, A. (2018). Exercises for pregnant and postpartum women with diastasis recti abdominis–literature review. Advances in Rehabilitation, 32(3), 27–35. https://doi.org/10.5114/areh.2018.80967 26. Leopold, M., Santiago, K., Cheng, J., Keller, L., Abutalib, Z., Bonder, J., . . . Casey, E. (2021). Efficacy of a core strengthening program for diastasis rectus abdominis in postpartum women: A prospective observational study. The Journal of Women’s & Pelvic Health. Physical Therapy, 45(4), 147–163. 27. Moolyk, A. N., Wilson, M. K., Matenchuk, B. A., Bains, G., Gervais, M. J., Wowdzia, J. B., & Davenport, M. H. (2025, February 3). Maternal and fetal responses to acute high-intensity resistance exercise during pregnancy. British Journal of Sports Medicine, 59(3), 159–166. https://doi.org/10.1136/bjsports-2024-108804 28. Wowdzia, J. B., Hazell, T. J., Berg, E. R. V., Labrecque, L., Brassard, P., & Davenport, M. H. (2023, September). Maternal and fetal cardiovascular responses to acute high-intensity interval and moderate-intensity continuous training exercise during pregnancy: A randomized crossover trial. Sports Medicine (Auckland, N.Z.), 53(9), 1819–1833. https://doi.org/10.1007/s40279-023-01858-5 29. Szumilewicz, A., Santos-Rocha, R., Worska, A., Piernicka, M., Yu, H., Pajaujiene, S., . . . Caro, M. A. O. (2022). How to HIIT while pregnant? The protocol characteristics and effects of high intensity interval training implemented during pregnancy: A systematic review. Baltic Journal of Health and Physical Activity, 14(1), 1–16. 30. Amawi, A., AlKasasbeh, W., Jaradat, M., Almasri, A., Alobaidi, S., Hammad, A. A., . . . Ghazzawi, H. (2024, January 18). Athletes’ nutritional demands: A narrative review of nutritional requirements. Frontiers in Nutrition, 10, 1331854. https://doi.org/10.3389/fnut.2023.1331854 31. Hrvatin, I., Rugelj, D., & Šćepanović, D. (2024, March 8). Pregnancy-related pelvic girdle pain affects balance in the second and third trimesters of pregnancy. PLoS One, 19(3), e0287221. https://doi.org/10.1371/journal.pone.0287221
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41
FOCUS A roundup of Fogarty’s published research from January to December 2025
PROFILE Rehnuma Haque, MD, PhD, studies blood lead levels of women in Bangladesh
Q&A Art Reingold, MD, recounts UC Berkeley’s impact on Fogarty’s AITRP program
DIRECTOR’S COLUMN Peter Kilmarx, MD, discusses Fogarty’s role in the America First initiative
N A T I O N A L I N S T I T U T E S O F H E A LT H • D E P A R T M E N T O F H E A LT H A N D H U M A N S E R V I C E S
Global Health Matters F O G A R T Y I N T E R N AT I O N A L C E N T E R
resources to conduct their analyses.
42 Delaware Journal of Public Health - December 2025
N OV/DEC 2025 I I SSU E 6
Photo courtesy of CIT
Fogarty researchers use NIH’s supercomputing
D I R EC TO R ’S C O LU M N I DR . PE T E R K I LM A R X
INVEST GLOBALLY, BENEFIT LOCALLY
an America-first global health strategy The new policy environment
IN SEPTEMBER 2025, the U.S. De-
never been “charity” or foreign aid.
provides an opportunity to
partment of State released the
They have always been mutually
“America First Global Health Strate-
beneficial. The new policy environ-
gy,” emphasizing that U.S. invest-
ment provides an opportunity to
articulate this more clearly: Fogarty’s global collabora-
ments in global health should
articulate this more clearly: Fogarty’s
tions have always and will
directly advance the health, secu-
global collaborations have always
always accelerate American
rity, and economic interests of
and will always accelerate American
innovation and make America
Americans. Around the same time,
innovation and make America health-
NIH issued updated guidance on
ier, stronger, and more prosperous.
healthier, stronger, and more prosperous.
2
maximizing and safeguarding foreign
In fact, the new alignment speaks
collaborations, underscoring that all
to the existing concept of recipro-
NIH-supported research conducted
cal innovation, a framework that
abroad should generate knowl-
recognizes innovation flows in both
edge applicable to understanding,
directions. Reciprocal innovation
improving, or protecting the health
promotes a bi-directional exchange
of people in the United States.
of ideas and solutions, driven by
Together, these policies reflect a
real-world needs, operational cre-
broader alignment of federal science
ativity, and the ingenuity of local
and foreign policy—global health
researchers and communities across
engagement must deliver clear value
global settings. Traditionally, global
back home.
health has emphasized the transfer
Fogarty’s longstanding mission
of technologies and practices from
and our unique experience place
high-income countries to low- and
us squarely at this intersection. For
middle-income countries (LMICs).
more than 55 years, Fogarty has
Yet LMICs also develop extraordi-
supported research, training, and
nary innovations, such as community
scientific partnerships around the
health worker models, mobile health
world, yet these investments have
platforms, point-of-care diagnostics,
GLOBAL HEALTH MATTERS
43
Global Health Matters
drone delivery networks, and frugal engineering approaches, all of which directly translate to the U.S. environment. A reciprocal innovation framework fits squarely within the America First Global Health Strategy with its emphasis on strengthening global disease surveillance, accelerating medical innovation, and fostering U.S. leadership through scientific partnership. These goals cannot be achieved in isolation. They require worldwide collaborative research networks that can detect emerging threats, generate new knowledge, and develop scalable solutions long before diseases reach U.S. shores. They also require understanding which global health approaches can be adapted for American challenges, particularly in rural, underserved, or resource-limited areas.
When we frame global health research around mutual benefit, we make clear how international partnerships advance U.S. health, innovation, and security. Examples already abound. Telemedicine platforms, originally deployed with community health workers in East Africa and other low-bandwidth settings, have also been adopted by U.S. clinics to extend specialist care in underserved communities. Service delivery models pioneered in sub-Saharan Africa, such as
differentiated HIV care and community adherence groups, have informed U.S. strategies for managing chronic conditions, including HIV and diabetes, in resource-limited settings. Pointof-care diagnostic innovations from south Asia, including lowcost molecular and rapid testing platforms, have helped shape U.S. approaches to expanding access to tuberculosis, COVID-19, and other essential diagnostics. And drone-enabled medical delivery systems first scaled in Rwanda have since been implemented in U.S. health systems to improve access to essential medical supplies in rural regions. Together, these examples demonstrate that investing in global health research strengthens both global and domestic preparedness. “America First” does not mean “America alone.” The health of Americans is inseparable from the health of the world. And some of the best ideas for improving U.S. health will continue to come from our partners abroad. By embracing reciprocal innovation and designing global health research with mutual benefit at its core, Fogarty can help lead the way toward a future where scientific collaboration makes America—and the world—healthier, safer, and more resilient.
Fogarty International Center National Institutes of Health Department of Health and Human Services
November/December 2025 Volume 25, Issue 6 ISSN: 1938-5935 Publishing Director Andrey Kuzmichev Editor-in-Chief Susan Scutti Contributing Writer/Editor Mariah Felipe-Velasquez Digital Analyst Merrijoy Vicente Graphic Designer Carla Conway
CONNECT WITH US
The Fogarty International Center is dedicated to advancing the mission of the National Institutes of Health by supporting and facilitating global health research conducted by U.S. and international investigators, building partnerships between health research institutions in the United States and abroad, and training the next generation of scientists to address global health needs.
fic.nih.gov Nov/Dec 2025
44 Delaware Journal of Public Health - December 2025
3
profile
Rehnuma Haque MBBS, MPH, PhD Fogarty Fellow 2020-2021 U.S. institution Stanford University Foreign institution icddr, b (formerly the International Center for Diarrheal Disease Research, Bangladesh) Research topic Assessing the prevalence of elevated Blood Lead Levels (BLLs) and possible sources of exposure among women of reproductive age in Bangladesh Current affiliation icddr,b with Dr. Stephen Luby, a professor of medicine at Stanford University. “Rahman and Luby found lead chromate contamination in turmeric, a South Asian spice that is widely used in curry,” says Haque.
Rehnuma Haque studies blood lead levels among textile workers
Bangladesh, home to 168.7 million people, is a lower-middle-income country striving to become a middle-income country. To accomplish this shift, it is industrializing rapidly. Rehnuma Haque, MBBS, PhD, says, “Everywhere different contaminants are present.”
With Luby’s mentorship, Haque won a Fogarty Fellowship, which allowed her to study blood lead levels among reproductive age female garment workers.
An adult population Bangladesh’s textile industry, which employs four million workers, is the country’s largest GDP sector, explains Haque. A majority of textile workers are women of reproductive age. Since these women carry the next
Photo’s courtesy of Rehnuma Haque
“We’re consuming or absorbing heavy
she completed her PhD, she searched
generation, the worry is that any lead
metals and pesticides through food,
for a postdoc opportunity to continue
they possibly absorb at work could
consumer products, air and water.
her research in this area. She reached
be passed onto their children. (Young
And arsenic contaminates our water,”
out to Dr. Mahbubur Rahman, Lead,
children are particularly vulnerable to
adds Haque. Concerned by the poten-
Environmental Health and WASH,
the build-up of lead in their bodies,
tial health effects, she focused her
at icddr,b, a world-renowned pub-
which can severely affect how they
PhD research on environmental toxi-
lic health research institute located in
grow and how their brains develop.)
cants and pesticide exposure. Once
Dhaka, Bangladesh. He collaborates
“This is the first study on reproduc-
4 GLOBAL HEALTH MATTERS 4GLOBAL GLOBAL HEALTH MATTERS HEALTH MATTERS
45
tive age women for lead contamina-
that time, which was a huge oppor-
tion. Before, we had some studies
tunity to learn the different apps
that focused on children, but this is an
and software. I learned how to do
adult population,” says Haque.
GIS mapping and conduct spatial
Her Fogarty project revealed that
analysis.”
A surprising year
all participants had some contamination from lead, while a substantial proportion, about 50%, had elevated
Rehnuma Haque (right) works with a colleague to collect and test a blood sample of a textile worker (middle).
Soon, Haque discovered a silver lining. “The pandemic created an opportunity for me to focus on
blood lead levels that exceed the CDC reference value of 3.5 micro-
She felt compelled to understand
COVID-related research. I wrote
gram per dl. “Our hypothesis was this
the invisible toxins that affect human
grant proposals and conducted
is caused by multiple sources of con-
health.
three SARS-CoV-2 environmental
“My father, who is a doctor, wanted
tamination in the garment factories,”
surveillance projects with funding
says Haque. To verify this, her team
me to become a doctor, so I com-
from UNICEF and the Rockefeller
examined different dyes, buttons and
pleted my MBBS degree at Dhaka
Foundation.” One of her projects,
colored threads.
University,” says Haque. A med-
which aimed to detect and assess
ical internship and master’s in
levels of the COVID delta variant in
ble lead contamination among these
public health followed, after which she
wastewater, helped identify commu-
potential sources. “We also visited
started working at icddr,b. Wanting
nity infection rates.
the participant households and col-
to continue learning, she applied to
When the lockdown lifted, Haque
lected floor dust, all the makeup that
the environmental health department
quickly restarted her stalled Fogarty
participants used (face powders, eye-
in Japan’s Kagoshima University and
project. “I’ve completed data collec-
shadows, nail polishes), their spices,
received a Monbukagusho scholar-
tion and built up a good rapport with
and a range of consumer products,”
ship to fund her PhD studies. “With
the garment factory workers and
says Haque. Here, the team’s analy-
that, my career shifted from clinical
already submitted a paper that’s soon
sis showed high lead contamination
doctor to public health doctor.”
to be published,” she says. Haque
Surprisingly they found negligi-
levels in house dust (and soil)—95%
Returning home from Japan, Haque
of house dust samples showed lead
resumed working at icddr,b and soon
support from Dr. Rubhana Raqib, icd-
contamination.
earned a spot in the 2020-21 cohort
drb; Dr. Jenna Forsyth and Dr. Erica Plambeck at Stanford University.
adds that she received invaluable
“If garment manufacturing is not
of Fogarty Fellows. Haque faced an
the primary source of contaminants,
obvious challenge during her Fogarty
A Fogarty fellowship has led to
there must be other environmen-
year. “It was 2020 and 2021 so the
many rewards, says Haque, who is
tal sources, which may include other
pandemic created substantial obsta-
now an assistant scientist leading her
nearby industries,” theorizes Haque.
cles.” The lockdown prevented her
own team of researchers at icddr,b.
Deceptive appearances
from going to Luby’s laboratory at
“The experience and skills I gained
In 1997, when Haque was a student,
Stanford, collecting data from her
have been instrumental in helping me
a team of researchers from Tokyo
own urban and peri-urban research
get subsequent funding.”
University visited her hometown, a
sites, and ordering a reagent for blood
remote village in Bangladesh, to study
lead testing. “The whole project got
possible arsenic contamination in
paused.”
water. “We always think contaminated
Yet Haque gained access to
water will look dirty, but our water
Stanford IT and its library, including
looks so clean, so transparent. Still
a prime IT resource for graduate stu-
they told us, ‘Don’t drink this water!’”
dents. “ArcGIS was free for me during Environmental Epidemiologist Rehnuma Haque
46 Delaware Journal of Public Health - December 2025
Nov/Dec 2025
5
RESEARCH ROUNDUP JANUARY-DECEMBER 2025
FOCUS 47
FOCUS I RESEARCH ROUNDUP
fogarty scientists in its division of international epidemiology and population studies conduct original research in epidemiology and mathematical modeling of diseases, genomic evolution of pathogens, implementation science, and population studies. Their work includes developing modeling techniques to enhance preparedness and improve response to pandemics and emerging health threats, all of which directly benefits the health and safety of Americans, explains David J. Spiro, PhD, the division’s director. “Fogarty researchers tackle a broad spectrum of global health challenges, from advancing influenza forecasting and HIV genomic surveillance to exploring innovative solutions for air pollution impacts, underscoring their pivotal role in addressing both domestic and international health issues.” The following studies were published between January and December, 2025. Photo courtesy of CIT
Biowulf, NIH’s supercomputer, is used across all NIH institutes and centers for a variety of research purposes. Nov/Dec 2025
48 Delaware Journal of Public Health - December 2025
7
FOCUS
Mobility data can help to reconstruct infectious disease dynamics and tailor control and elimination measures, according to the authors of this study. Using computational models, they describe three challenges and opportunities to improve understanding of human mobility for infectious disease research. They conclude by making a case for increased modeling and simulation, more advanced reporting guidelines, and greater investment in data repositories. Fogarty’s Chelsea Hansen, PhD, Cécile Viboud, PhD, and Amanda Perofsky, PhD, contributed to this work. Article: Improving mobility data for infectious disease research. Publication: Nature Human Behavior
This hospital network protects global health
Courtesy of Influenza and Other Respiratory Viruses
The Global Influenza Hospital Surveillance Network (GIHSN), a worldwide collaboration, tracks serious respiratory illnesses in hospitals. Since 2012, it has collected detailed information on patients, including symptoms, demographics, and virus testing. The network now spans more than 100 hospitals in 27 countries, covering nearly 168,000 patients and identifying tens of thousands of cases of influenza and other respiratory viruses. GIHSN’s reliance on public–private partnerships and pre-existing national systems makes it flexible, scalable, and adaptable to new threats like COVID-19. By standardizing data collection and fostering global cooperation, GIHSN guides public health response, improves pandemic preparedness,
8
How well did the 2023 flu vaccine work? Influenza, or the flu, is a common virus that affects young and old alike and causes illness that ranges from mild to severe (requiring hospitalization). The virus changes frequently, so vaccines must be updated each year. This study looked at how well the 2023 southern hemisphere flu vaccine protected people across eight countries, using data from 520 hospitals. Results showed the vaccine reduced hospital admissions by about half; it worked especially well in young children and somewhat less effectively in older adults. Protection against severe disease requiring intensive care was even higher. Vaccine effectiveness varied between countries, likely due to differences in flu strains, timing of
vaccination, population health, and
Courtesy of the CDC
Enhance data streams to advance infectious disease research
and provides insights for disease control strategies. Fogarty’s Cécile Viboud, PhD, and her co-authors conclude that GIHSN exemplifies the value of integrating research with public health initiatives through global collaboration and public–private partnerships. Article: The Global Influenza Hospital Surveillance Network: A Multicountry Public Health Collaboration. Publication: Influenza and Other Respiratory Viruses
vaccine types. The authors, Fogarty’s former director Kathleen Neuzil, PhD, and Cécile Viboud, PhD, state that large multi-country studies help scientists develop better vaccines. Article: Harnessing the power of multicountry networks for influenza vaccine monitoring. Publication: The Lancet Global Health
Tracking flu viruses in Southeastern Asia Southeastern Asia plays a key role in spreading seasonal flu around the world. Researchers studied flu virus movement in this region from 2007 to 2023, including during the 2009 H1N1 and COVID-19 pandemics. The study showed that COVID-19 greatly disrupted flu spread, stopping the usual waves of influenza virus movement; the 2009 H1N1 pandemic had a smaller effect. The A/H3N2 flu virus persisted more in the region than the B/Victoria virus, while patterns of virus evolution changed
depending on the pandemic. Human travel, immunity, and behavior during
Data from the Global Influenza Hospital Surveillance Network
This chart shows the distribution of viral infections by season.
GLOBAL HEALTH MATTERS
49
pandemics affect flu circulation; understanding these patterns helps improve surveillance, vaccine planning, and preparation for future pandemics, noted the authors, including Fogarty’s Cécile Viboud, PhD. Article: Disruption of seasonal influenza circulation and evolution during the 2009 H1N1 and COVID19 pandemics. Publication: Nature Communications
conclude that enhanced RSV testing, monitoring of respiratory viruses, and ongoing vaccination is needed. Article: Excess mortality and hospitalisations associated with respiratory syncytial virus, influenza, and COVID19 Publication: The Lancet Regional Health: Europe
New RSV shots could prevent hospitalization of infants and seniors
What data from Denmark reveals about hospitalizations, deaths linked to respiratory viruses A study in Denmark focused on three respiratory viruses—RSV, influenza, and COVID-19—and their impact on adults from 2015 to 2024. All three viruses caused significant deaths and hospitalizations, especially among people aged 65 and older. RSV, often overlooked in adults, caused nearly as many hospital admissions as influenza in older adults, with post-pandemic seasons seeing higher RSV activity. Influenza and COVID-19 also caused serious illness, though widespread vaccination helped reduce this. While COVID-19 lockdowns temporarily lowered the spread of all respiratory viruses, RSV and influenza rebounded after restrictions lifted. Fogarty’s Cécile Viboud, PhD, Chelsea Hansen, PhD, and their co-authors
Could vaccines and antibody treatments for respiratory syncytial virus (RSV) prevent hospitalizations in King County, Washington? RSV can be a serious respiratory infection, especially for babies and older adults. During the 2023–2024 season, new immunizations protected some infants and seniors, preventing about 125 hospitalizations. Infants under 6 months and adults over age 75 saw the biggest benefits. The study predicted that if more people got vaccinated early in the 2024–2025 season, up to 69% of infant hospitalizations, and 30% of hospitalizations in older adults could be avoided. Fogarty’s Chelsea Hansen, PhD, Cécile Viboud, PhD, Amanda Perofsky, PhD, and Kaiyuan Sun, PhD, contributed to this study. Article: Excess mortality and hospitalisations associated with respiratory syncytial virus, influenza, and COVID-19 Publication: The Lancet Regional Health: Europe
The surface of human lung epithelial cells shedding RSV virions (colorized blue).
time and found that RSV-A was the dominant strain. Nonetheless, influenza infection was more strongly associated with ICU admission than an RSV infection. Infection rates rose and then fell once precautions to control COVID-19 were implemented. Genetic analysis revealed new viral mutations and also showed that RSV often enters Pakistan through travelers from Europe. Multiple viral lineages circulated simultaneously, sometimes quietly spreading outside peak seasons. Understanding these patterns can guide effective treatment and prevention strategies in Pakistan and other countries, suggested Fogarty’s Nidia Trovão, PhD, and her co-authors. Article: Evolutionary trajectory and spread of respiratory syncytial virus group A in neonatal cohorts. Publication: Science Reports
Predicting interactions between RSV and hMPV
Tracking RSV movement and evolution to protect infants in Pakistan
Respiratory syncytial virus (RSV) and human metapneumovirus (hMPV)
From 2019 to 2022, researchers studied respiratory syncytial virus (RSV) in children under 2 years old in Pakistan. They tracked how it spread, changed genetically, and evolved over
mainly in children. Scientists noticed that hMPV outbreaks usually follow RSV outbreaks by a few weeks, suggesting that RSV temporarily reduces hMPV’s spread. Using mathematical models and
are viruses that cause lung infections,
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Photo courtesy of NIAID
Courtesy of NIAID
Swine flu virus particles (green) attach to and bud from the surface of a cell (purple).
Influenza and COVID-19 caused serious illness, though widespread vaccination helped reduce this.
FOCUS data from Scotland, Canada, and Korea, researchers found evidence for this “suppressive effect,” where RSV infections lower hMPV transmission. The study also looked at what could happen if new RSV vaccines and treatments reduced RSV infections. Their models predict that hMPV outbreaks might shift in timing or size, but overall, hMPV cases are unlikely to surpass the original RSV burden. This research, co-authored by Fogarty’s Cécile Viboud, PhD, could help guide planning for vaccines and public health response. Article: Using COVID-19 pandemic perturbation to model RSV-hMPV interactions. Publication: Nature
Lessons for a future hMPV vaccine This study looked at human meta-pneumovirus (hMPV), a respiratory virus that can cause coughs, runny noses, and fever, especially in young children and older adults. Examining Seattle data collected between 2018 and 2022, the researchers found that the group most likely to test positive were children under age 5, while people with lower household incomes or recent international travel showed higher risk of infection than others. During the COVID-19 pandemic, infection rates dropped overall, though areas of lower socioeconomic
status showed higher rates compared to other neighborhoods. Genetic testing revealed that multiple virus subtypes circulated before the pandemic, with the mix altered after the pandemic. Fogarty’s Cécile Viboud, PhD, Amanda Perofsky, PhD, and their co-authors recommend that developers of vaccines target parts of the virus shared across all subtypes. Article: Epidemiology of Human Metapneumovirus Infection in a Community Setting, Seattle, Washington, USA. Publication: The Journal of Infectious Diseases
Communications
Understanding hMPV: How a virus spreads in Côte d’Ivoire
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This colored map segments the U.S. into 15 unique zones based on temperature and moisture levels.
Floods, dust storms & rising lung disease across the U.S. Nontuberculous mycobacteria (NTM) are bacteria found in soil and water that can cause long-lasting lung infections, especially in people with lung problems or cystic fibrosis. This study looked at NTM cases across the U.S. and compared them with weather patterns and severe events like floods and dust storms. The researchers found that NTM infections have been rising and that certain weather conditions—such as high temperatures, heavy rain, cloud cover, and changes in air pressure—are linked to higher infection rates. Floods in the Southeast and dust storms in mid-lati-
tude regions were especially strong predictors. The timing between weather events and later increases in infections varied by region. The authors, including Fogarty’s Samantha Bents, highlight the need for better testing, reporting, and awareness. Article: Factors predicting incidence of nontuberculous mycobacteria in an era of altered ecosystems in the United States, Publication: The Science
Courtesy of The Science of the Total Environment
Researchers studied human metaneumovirus (hMPV) in Côte d’Ivoire by examining samples collected from 3,899 children under age 5 between January 1, 2013 to December 31, 2015. They found that about 6% of the children had hMPV, which causes respiratory infections and circulates year-round, peaking during the dry season. Genetic analysis revealed two main virus groups (A and B) with multiple lineages; analysis also showed repeated introduction of the virus into the country, often from Asia. Most infections were mild. Results indicate that hMPV contributes to the high rates of respiratory illness in young children and that continuous monitoring is necessary to track new strains, guide vaccine development, and improve public health response. Fogarty’s Nidia Trovão, PhD, and Josh Cherry, PhD, contributed to this report. against SARS-CoV-2. Article: Repeated introductions and widespread transmission of human metapneumovirus in Côte d’Ivoire. Publication: BMC Infectious Diseases
of the Total Environment
Why tracking MERS requires multiple methods This study looked at transmission of the Middle East Respiratory Syndrome (MERS) virus and how well different scientific tools can track its spread and
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VIRUSES CHANGE MOST RAPIDLY WHEN IMMUNITY IS NEITHER TOO WEAK NOR TOO STRONG—THIS IS CALLED THE “PHYLODYNAMIC CURVE.”
movement between cases. Researchers analyzed more than 600 virus genomes collected from 2012 to 2024. All methods confirmed that MERS mainly spreads from infected dromedary camels to humans, mostly in Saudi Arabia and the United Arab Emirates. However, the tools did not always agree on how often these “spillover” events happened—some estimated as few as 15 while others estimated as many as 34. The researchers recommend using fast tools for quick outbreak detection and a multi-method review for long-term planning. Continued genomic monitoring of both camels and humans is essential for catching new MERS threats early. Fogarty’s Nidia Trovão, PhD, contributed to this article. Article: EA scalable maximum-likelihood framework for near-real-time monitoring of MERS-CoV evolutionary and zoonotic dynamics.USA. Publication: Microbiology Spectrum
Predicting how viruses outsmart immunity Viruses change most rapidly when immunity is neither too weak nor too strong—this is called the “phylodynamic curve.” Here, Fogarty’s Cécile Viboud, PhD, and co-authors develop a new framework to better understand how viruses evolve to escape immunity in a population. The framework shows how
Dengue in Saudi Arabia: Tracking a virus across borders A recent study of dengue virus (DENV) in Saudi Arabia analyzed 20 full virus genomes collected between 2021 and 2023. Researchers found three types of dengue co-circulating there— DENV-1, DENV-2, and DENV-3—the most common being DENV-2. The viruses were repeatedly introduced from countries in South and Southeast Asia and East Africa. Some strains had been circulating in Saudi Arabia undetected for years, showing both ongoing local spread and the country’s role as a hub for regional transmission. Mass gatherings, international travel, and labor migration increased the risk of dengue spread. The study highlights the urgent need for better virus monitoring, stronger mosquito control, and regional cooperation to track outbreaks and reduce disease impact. Fogarty’s Nidia Trovão, PhD, co-authored this study. Article: Molecular evolutionary insights into the repeated introductions and cryptic transmission of dengue virus Publication: The Journal of Infectious Diseases
Pigs on a farm
From import to outbreak: The story of PRRSV-2 in Costa Rica Porcine Reproductive and Respiratory Syndrome Virus (PRRSV-2) is a serious disease that harms pigs’ health and costs farmers millions. In Costa Rica, the first outbreak appeared in 1995–1996, causing piglets’ deaths, breathing problems, and skin lesions. Research shows that the virus likely arrived through imported pigs from the U.S. and possibly Japan, spread between farms, and evolved over decades. A study of the virus’s genetic material revealed its history, movement, and changes. Vaccines introduced in 2021 reduced infections and improved pigs’ health, but PRRSV-2 still persists. The study highlights the risks of global livestock trade and shows how animal diseases can spread internationally and impact food security and economies. Fogarty’s David Spiro, PhD, and Nidia Trovão, PhD, contributed to this research. Article: Integrating phylodynamics and historical records reveals decades-old introductions of PRRSV into Costa Rica Publication: bioRxiv (preprint)
Age shapes our defenses against respiratory viruses This study looked at how people’s immunity to common respiratory viruses changed during and after the COVID-19 pandemic. Because many viruses barely circulated during lockdowns, people missed normal exposures that help keep immunity strong. Using blood samples
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Photo courtesy of Liz West
Courtesy of NHGRI
Researcher examines DNA output.
factors like partial immunity, vaccination, seasonal outbreaks, travel, and public health measures affect the risk and timing of the emergence of new virus variants. For example, partially protective immunity and the lifting of interventions (such as mask mandates) can influence when and where immune-evading variants appear. By understanding these dynamics, public health officials can better prevent outbreaks of dangerous viral variants, improve vaccine strategies, and reduce the risk of immune escape. Article: Eco-evolutionary dynamics of pathogen immune-escape: deriving a population-level phylodynamic curve. Publication: Journal of the Royal Society Interface
FOCUS
Publication: medRxiv (preprint)
This overlooked gene may make COVID-19 worse
Publication: Molecular Biology Evolution
Tracking COVID-19 spread using virus genetics Researchers analyzed over 114,000 SARS-CoV-2 virus genomes collected in
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Washington State to better understand how COVID-19 spread between people, places, and age groups. They focused on pairs of identical virus sequences, enabling them to trace how infections moved across counties and communities. This new method, which entails quick analyses of large datasets of virus genomes, reveals hidden transmission networks that traditional approaches might miss. The study showed that most transmission occurred locally, with some unusual patterns linked to male prison facilities acting as hubs for virus spread. Human movement patterns (commuting and travel) strongly explained the geographic spread of the virus. Insights derived from this study can help health officials plan interventions, such as testing, vaccination, or travel guidelines, to prevent or limit future outbreaks, suggest Fogarty’s Cécile Viboud, PhD, Amanda Perofsky, PhD, and their co-authors. Article: Fine-scale patterns of SARSCoV-2 spread from identical pathogen sequences. Publication: Nature
Mental health improves after COVID-19 pandemic in Costa Rica A study in Costa Rica tracked the mental health of 1,459 people from mid-2021 to late 2023 to see how COVID-19 affected psychological distress. During the pandemic, about 14% of participants reported distress, but this dropped to under 9% after the pandemic, when improvements in overall mental health scores were seen—14.5% of people showed large improvements, though 5.3% experienced deteriorating
Publication: Public Health
The power (and limits) of using genomes to track outbreaks Scientists use pathogen genome sequences to study how diseases spread between groups of people or animals. These sequences change over time as the pathogens mutate; the speed of mutation compared with the speed of disease transmission affects how much scientists can learn. Fast-mutating pathogens can reveal more detailed movement patterns, while slow-mutating ones may show only broad trends. The number of samples also matters—more samples give a clearer picture of how a disease spreads. This study introduces a framework to understand the limits of what genome data can reveal, while strategies like grouping populations, analyzing longer genome segments, or using deep sequencing may improve accuracy. Fogarty’s Amanda Perofsky contributed to this work Article: Characterizing the informativeness of pathogen genome sequence datasets about transmission between population groups. Publication: medRxiv (preprint) Output from a DNA sequencer
Courtesy of NHGRI
ORF10 is a tiny and often overlooked gene found only in SARS-CoV-2, the virus that causes COVID-19. Researchers examined millions of virus samples and found that ORF10 has barely changed since the start of the pandemic, suggesting that it plays an important role in virus survival. Mutations in ORF10 were rare, but when they did occur, a few were linked to milder COVID-19 symptoms, none were linked to worse symptoms. Lab tests showed that ORF10 expression can disrupt how human cells produce energy in their mitochondria, which weakens early immune defenses. These effects may help the virus survive longer and could play a role in severe illness or long COVID. Fogarty’s Nidia Trovão, PhD, and her co-authors recommend studying ORF10 more extensively. Article: Importance of De Novo Gene Evolution to Emerging Viral Threats
SARS-CoV-2 (round blue objects) emerges from the surface of cells; the virus depicted here was isolated from a patient in the U.S.
symptoms. Improvements were seen in both men and women and in most age groups, except teenagers (12–17 years). The pandemic increased stress due to fears of infection, social isolation, economic troubles, and loss of loved ones. This study highlights community resilience and the importance of monitoring and supporting mental health during global crises. Fogarty’s Kaiyuan Sun, PhD, contributed to this research. Article: Trends in psychological distress during and after the COVID-19 pandemic: a Costa Rican cohort study.
Courtesy of NIAID
from Seattle and older data from South Africa, researchers found that children under age 5 lost antibodies much faster than adults but also gained them more quickly once viruses returned. Adults showed little drop in immunity. When these age-based patterns were added to a disease-spread model, they helped explain why influenza came back so strongly in 2022–23 and why more older children needed medical care. Overall, age plays a major role in how immunity builds and fades, conclude Fogarty’s Cécile Viboud, PhD, Amanda Perofsky, PhD, Chelsea Hansen, PhD, Samantha Bents, and their co-authors. Article: Multiplex serology reveals age-specific immunodynamics of endemic respiratory pathogens
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NEWS&Updates Applicant news—research security training required in 2026 affiliation disclosures are then routed to the Research Compliance and Regulatory Affairs office for security risk assessment. For some new hires and international scholars, a management plan may be a condition for collaboration.
Research security training (RST) Research security training helps ensure compliance with the CHIPS and Science Act of 2022, the National Security Presidential Memorandum-33 (issued on January 14, 2021), and other federal requirements. The CHIPS Act provides funds to support the domestic production of semiconductors and authorizes various programs and activities of the federal science agencies. The National Security memo aims to safeguard U.S. government-supported research endeavors against foreign government interference and exploitation. The intentions of both are to maintain an open environment fostering scientific discoveries and innovation that benefit both the U.S. and the world, while protecting intellectual capital, discouraging research misappropriation, and ensuring responsible management of U.S. taxpayer dollars. To comply with federal requirements, new hires and international visiting scholars need to disclose foreign contracts, affiliations, and involvement with foreign talent recruitment programs during the onboarding process. Any foreign
A scientist works with the NSF Secure Center condensed RST module.
QUESTIONS? Please direct your
inquiries to: NIH Office of Policy for Extramural Research Administration (OPERA) operaleadership@NIH.gov.
Here’s a list of need-to-know information RST REQUIREMENT The new RST requirement stipulates each covered individual on a grant application must certify that they have completed their training within 12 months of the application submission date. Covered individuals are defined as senior and/or key personnel employed by the institution and listed on the application. EFFECTIVE DATE OF THIS REQUIREMENT Completion of RST and the individual and institutional certifications will be effective for applications with deadlines on or after May 25, 2026. CERTIFICATION PROCESS Applicant institutions need to certify that each senior/key personnel employed by the institution and listed on the application has completed RST. The Authorized Organization Representative (AOR), via their signature on the face page of the application, will certify the applicant institution’s compliance with this requirement. COMPLETION DATE FOR TRAINING All senior/key personnel listed on an NIH grant application must certify that they have completed RST within 12 months of the date of application submission. COLLECTION PROCESS NIH will collect individual certifications at the time of the application submission, through the Biographical Sketch in SciENcv.
TRAINING MODULES The National Science Foundation (NSF), in partnership with the National Institutes of Health (NIH), the Department of Energy (DOE), and the Department of Defense (DOD), provided four online RST modules as a resource to the extramural community. Subsequently, the NSF Secure Center, a site where members of the U.S. research community can manage security requirements, developed an updated and condensed RST module that is compliant with government-wide RST requirements. The condensed module is here: https://www.secure-center.org/ctm Nov/Dec 2025
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Courtesy of the NSF Secure Center
Heads up, Fogarty grant applicants! Currently, research security training is optional for extramural researchers funded by the National Institutes of Health. In the coming year, completion of this training will be required for all applications submitted on or after May 25, 2026.
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Arthur L. Reingold, MD
Q&A
Doing what seems useful—a Q&A with Art Reingold Arthur L. Reingold, MD, recently retired from his position as a professor of epidemiology at the University of California, Berkeley School of Public Health. His previous experience includes working for eight years at the U.S. Centers for Disease Control and Prevention and serving as director (or co-director) of the CDC-funded California Emerging Infections Program since 1994. His research interests comprise vaccine-preventable diseases; respiratory infections; bacterial meningitis; disease surveillance; and outbreak detection and response. He’s published more than 400 related research papers. In 2003, he was elected to the Institute of Medicine of the National Academy of Sciences. In November, the UC Berkeley School of Public Health announced the
Fogarty put out a request for applications for the AIDS International Training and Research Program (AITRP). We had a very good group of AIDS researchers in the San Francisco Bay area and I convinced my colleagues at University of California, San Francisco to let me be the P.I., even though that’s not the usual approach. So UC Berkeley-UCSF became one of AITRP’s first funded programs and continued receiving funds until AITRP ended in 2011.
launch of its Reingold Institute for Global Health to honor his work in the field.
How do you judge UC Berkeley’s work with AITRP?
What part of your education was most influential/beneficial?
The main reason for the program was to train people from low-income countries heavily burdened by AIDS and then help them return home and establish themselves there. So, how successful was that? Pretty much all of our Brazilian trainees went home. I can think of only a couple who stayed in the U.S., but they almost all went back. Brazilians like Brazil, frankly, and there’s a good reason for that. Almost all of our trainees from Uganda went back to Uganda and the ones that didn’t are either in Rwanda or other nearby countries with few exceptions. But almost nobody went back to and stayed in Zimbabwe. Sitting in my nice house in California with a wellpaid job, I can’t blame them. I always thought, Who the hell am I to tell somebody to go back to Zimbabwe where they wouldn’t be able to use their skills and wouldn’t be able to afford to send their kids to school?
Do you know who Berton Roueche was? He was a writer for The New Yorker magazine and his stories are collected in books; “The Medical Detectives” is about outbreak investigations. After reading his work, I decided I wanted to concentrate on infectious diseases, and the pathway that made sense was to stay with the CDC’s Epidemic Intelligence Service (EIS) program. Basically I fell in love with the “medical detective” aspect of the CDC. I spent my first year in the Connecticut State Health Department, where I did some interesting investigations and then I moved to Atlanta for my second year. There I became one of the world’s leading male experts on tampons when I investigated toxic shock syndrome. (Toxic shock syndrome is a complication of Staphylococcal infections linked to skin wounds, surgery, and use of 14
tampons and other vaginal products.) I also investigated Legionnaires’ disease and other outbreaks in the U.S., Canada and the Netherlands. I had my first global health experience looking at the effectiveness of a vaccine against meningitis for CDC. Every meningitis season I would go to Ouagadougou, which is the capital of what was then Upper Volta (now Burkina Faso) in West Africa. Upper Volta was one of the half-dozen poorest countries in the world, so I came face-to-face with what real poverty looks like and I came to understand the challenges experienced by low-income countries. I also went to Nepal to work on meningitis for the World Health Organization and saw more of the global picture there. How did you come to work with Fogarty?
Soon after I joined the faculty of Berkeley’s School of Public Health,
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Still most of our trainees did return to their countries and have become leaders in their fields and done phenomenal things. AITRP changed the lives of many, and I believe we contributed to the global public health infrastructure. Do you see any new trends in global health research?
Art Reingold speaks with a former trainee, Akila Govindarajan Venguidesvarane of Sri Ramachandra Institute of Higher Education and Research
who work at Gilead, and they’ve been quite generous in supporting our global health work over the past few years. So for some people— people who make new drugs, new vaccines—a career in the private sector is how they can best contribute. We should be doing more partnerships with the private sector than we’ve done in the past and I say that fully recognizing the downsides and challenges.
Art Reingold entertains trainees at home
“
Is there anything else you’d like to share with our readers?
I sort of bumbled through the last 40 years doing things that seemed useful, without focusing on a particular pathogen or a particular disease as many of my academic colleagues have. So maybe that’s why I didn’t win the Nobel Prize! But I like to think that I’ve had an impact and if I have, support from Fogarty was a major contributing factor.
AITRP CHANGED THE LIVES
OF MANY, AND I BELIEVE WE CONTRIBUTED TO THE GLOBAL PUBLIC HEALTH INFRASTRUCTURE.
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Photos courtesy of Arthur Reingold
I think the work to decolonize global health is important. I also want people to be energized and encouraged to do great things, so we need to do a better job of making sure our students have the right skill sets. Those skill sets are getting more complicated all the time and this reality complicates what the future looks like in terms of funding, priorities, etc. Today we have funding for some global health work from industry. This is new. We’re fortunate to have a partnership with Gilead, which makes lenacavapir, the shot that you only need twice a year to not get HIV. I have a lot of former students
NEWS&Updates Courtesy of Bruce Butrum
How a ‘practical’ career path led to unexpected fulfillment Bruce Butrum, Fogarty International Center’s Chief Grants Management Officer, will retire in January 2026. “Bruce combined unmatched technical expertise with extraordinary generosity of spirit, becoming the beating heart of Fogarty’s grants operation for nearly a quarter century,” said Fogarty’s Acting Director Peter Kilmarx, MD. “He leaves a lasting legacy in the systems he developed and the colleagues he inspired at Fogarty, across NIH, and around the world.”
Heartfelt work wanted Butrum’s earliest government jobs included six years working as an auditor for the U.S. Army and Navy. Although he learned a lot, something more was needed. “I interviewed at the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and they asked if I wanted to be a grants management specialist—I had no idea what that is, still I said, ‘Sure!’” says Butrum. He soon learned that a grants management specialist means “working as a team with the program officer to manage the grant. In other words, the program person’s the science piece and you’re the administrative money person plus the compliance person.” At NIDDK Butrum met his most influential mentor. Tom Turley, well on his way to becoming NIDDK’s chief grants management officer (CGMO), took Butrum under his wing and showed him the ropes of reviewing grant applications. “Tom was very inclusive.” Turley followed Butrum’s recommendations, working closely with him to develop procedures and establish terms and conditions for the grants. Later, when Turley became CGMO at the National Heart, Lungs and Blood Institute (NHLBI), he suggested Butrum transfer with him to continue their systemic improvements together. Eventually, Turley transferred to NIH’s Office of the Director. Butrum stayed put, but continued to work with his mentor. The NIH-wide procedures they devised became some of the standards still in use today. Meanwhile, Butrum led NHLBI’s clinical trials review committee; “I worked on some seminal heart trials, such as bypass versus angioplasty.” Still, Butrum felt compelled to continue growing. In 2001, he landed the position of CGMO at Fogarty. A different ICO “Fogarty didn’t have a real grants office, so they hired me to develop one,” recalls Butrum. “I hired people, trained people, established all the procedures and checklists, and created terms and conditions.” Butrum discovered that, as CGMO, he could provide critical input regarding Fogarty programs. “For example, I suggested that we launch a small R01 program for our trainees and that became the Global Research 16
Bruce Butrum
Initiative Program for New Foreign Investigators (GRIP).” He took full advantage of Fogarty’s peculiarities when making suggestions, including the fact that the D43 (an international research training grant) was a mechanism created by Fogarty itself. “So with the LAUNCH Program, I said, ‘Let’s use the D43, because it’s ours, and nobody’s going to argue with us about it.” Another triumph: Butrum devised the unique model of the GeoHealth program: two separate grants that work as a pair—one at a foreign institution, another at a linked U.S. institution. Butrum also became involved with many cross-cutting NIH policies and systems. He helped create and develop the SNAP process and the Modular Grant Pilot; he also helped design and launch the foreign tracking system (now called the FACTs system) that operates between the State Department and divisions within the Department of Health and Human Services. He gives credit to his team—Mollie Shea, Vicki Tran, Satabdi Raychowdhury, and La Bria Williams—for enabling this work. Butrum recognizes the rare privilege of working at Fogarty, which has, undoubtedly, changed the lives of millions of people worldwide. “I believe God put me in this position as Fogarty’s CGMO for the past 24-plus-years so that I could do the most good.”
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Global HEALTH Briefs HPV vaccine: single shot proves non-inferior to double shot A single HPV vaccination could be as effective as two shots to prevent the virus that causes cervical cancer. A National Cancer Institute (NCI)-funded study enrolled more than 20,300 girls between ages 12 and 16 and randomly assigned each to receive one or two doses of a bivalent HPV vaccine or one or two doses of a nonavalent HPV vaccine. The bivalent vaccine protects against HPV types 16 and 18 that cause most HPV cancers; the nonavalent vaccine protects against HPV types 16 and 18 as well as additional, lower-risk HPV types. The study tracked the girls to see if they developed a new HPV type 16 or 18 infection between months 12 and 60 that persisted for at least 6 months. Vaccine effectiveness measured at least 97% in each of the four trial groups. The New England Journal of Medicine published this study. Case fatality rate of 50% in Ethiopia’s first ever Marburg virus outbreak As of December 3, 2025, Ethiopia has reported 13 laboratory confirmed cases of Marburg virus disease (MVD), eight of which were fatal, according to the U.S. Centers for Disease Control and Prevention. This is Ethiopia’s first outbreak of MVD; originally reported by the Ministry of Health on November 14, it affects the South Ethiopia and Sidama regions. Minister Mekdes Daba said Ethiopia is working with countries that previously experienced Marburg outbreaks to exchange expertise and to access investigational treatments and experimental vaccines that have yielded positive results. MVD is a rare but highly fatal viral hemorrhagic fever caused by infection with one of two viruses, Marburg virus or Ravn virus, both within the Filoviridae family, which includes Ebola virus. Diet quality linked to risk of depression during pregnancy in Nepal New research published in Maternal and Child Nutrition explores the association between overall diet quality and risk of depression during pregnancy among women in Nepal, a lower-middle-income country with high rates of nutritional deficiencies and unmet mental health needs. The study found that 22.3% of pregnant women in their third trimester showed elevated depressive symptoms. Higher intake of whole fruits, vegetable oil, and refined grains was associated with a lower risk of depression, while frequent consumption of processed meats, sweets, fried foods, sweetened drinks, fish, beans/pulses, and whole grains was linked to a higher risk of depression. Shaun Ranade, a medical student and Fogarty-Fullbright awardee, contributed to this work.
Can data science improve sustainability of health research? Fogarty’s Laura Povlich, PhD, Amit Mistry, PhD, and Gifty Dankyi, MS, co-authored a research paper on the Data Science for Health Discovery and Innovation in Africa (DS-I Africa) initiative. DS-I Africa includes 38 projects that use tools, such as artificial intelligence, big data, and genomics, to address major health challenges, including cancer, malaria, and air pollution. To foster strong partnerships, DS-I Africa runs Networking Exchange events where people can meet and form multidisciplinary collaborations across countries and regions. The program, which is supported by Fogarty, the NIH Common Fund and other NIH institutes, nears the end of its first funding phase in 2026 and has begun planning for long-term sustainability, according to the report published in Data Science Journal. Experimental vaccine shows strong protection against typhoid, salmonella University of Maryland researchers tested a new vaccine that may protect against both typhoid fever and dangerous non-typhoidal Salmonella infections, significant health concerns globally. In an early phase clinical trial for safety, 22 healthy U.S. adults received either the vaccine or a placebo. Those who received the vaccine, which showed no safety concerns, developed strong immune responses. The National Institute for Allergies and Infectious Disease supported this study published in Nature Medicine. All text produced in Global Health Matters is in the public domain and may be reprinted. Please credit Fogarty International Center. Images must be cleared for use with the individual source, as indicated. In rare cases when a correction is needed after an issue’s printed version has been finalized, the change will be made and explained in the online version of the article.
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Dieffenbach joins Fogarty as a senior advisor Carl Dieffenbach, PhD, has joined Fogarty International Center as senior advisor to the director. Previously, Dieffenbach served as director of the Division of AIDS (DAIDS) at the National Institute of Allergy and Infectious Diseases, where he oversaw a global HIV/AIDS research portfolio of more than $1 billion. In 1984, he earned a PhD in biophysics (with a focus on virology, specifically human responses to viruses including the production of interferon and interferon-induced genes) from Johns Hopkins University. Following completion of his postdoctoral research at Uniformed Services University of the Health Sciences, he was promoted to assistant professor and his lab worked on flu, coronavirus, and HIV. In 1992, he joined DAIDS as the chief of the preclinical therapeutics group, where he spearheaded initiatives that accelerated the progress of basic research on HIV pathogenesis and directly resulted in new clinical studies of novel AIDS therapies. In 1996 he was promoted to director of the DAIDS Basic Sciences Program, and in 2008 he earned a promotion to division director.
Binagwaho receives Cameron Award The Royal College of Surgeons in Ireland University of Medicine and Health Sciences has presented the Cameron Award for Population Health to Agnes Binagwaho, MD, PhD, professor at, and co-founder and former Vice Chancellor of, the University of Global Health Equity in Rwanda. The Cameron Award for Population Health recognizes leaders who have made outstanding contributions to public health. Binagwaho returned to Rwanda in 1996 following the 1994 Genocide against the Tutsi and helped rebuild the country’s health system. Between 2002 and 2011, she served in senior government positions, including executive secretary of the National AIDS Control Commission and permanent secretary of the Ministry of Health. In 2011, she was appointed and then served five years as Minister of Health. Binagwaho, who has authored more than 250 peerreviewed publications, holds appointments at Harvard Medical School and Dartmouth’s Geisel School of Medicine.
Heimburger, former Fogarty Advisory Board member, retires Douglas Heimburger, MD, has retired from his position as professor emeritus in Vanderbilt University Medical Center’s Division of Epidemiology. Heimburger served on Fogarty’s Advisory Board from 2004 to 2008, and from 2009 to 2012 co-led the Fogarty International Clinical Research Scholars and Fellows program, a discontinued program for doctoral students. He also led the Vanderbilt-Emory-Cornell-Duke Global Health Fellowship Consortium, part of Fogarty’s Fellows & Scholars/Launching Future Leaders in Global Health Research Training Program and served as principal investigator for the HIV-NCD Research Program, an ongoing University of Zambia-Vanderbilt Training Partnership grant that’s provided educational opportunities for global health scientists since 1998. For 20 years Heimburger directed the NIH-funded Cancer Prevention and Control Training Program within the Departments of Nutrition Sciences and Medicine at the University of Alabama at Birmingham before he joined Vanderbilt in 2009.
Dheda wins Princess Chichibu Memorial TB Global Award Keertan Dheda, PhD, received the 2025 Princess Chichibu Memorial TB Global Award, which is presented by the Japan Anti-Tuberculosis Association, for his outstanding scientific contributions to anti-tuberculosis activities. Dheda is a professor of mycobacteriology and global health at the London School of Hygiene and Tropical Medicine. He holds a joint appointment at the University of Cape Town, South Africa, where he is the director of the Centre for Lung Infection and Immunity. A National Institute of Allergy and Infectious Diseases grantee, Dheda has published a series of seminal papers on the epidemiology, transmission, and management of drug-resistant TB. He’s contributed to capacity building in lower-income countries with programs at New York University and South Western Medical School in Dallas. He serves in an editorial advisory role at Lancet Respiratory Medicine. 18
GLOBAL HEALTH MATTERS
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people
Sears receives Alexander Fleming Award for Lifetime Achievement The Infectious Diseases Society of America (IDSA) honored Cynthia Sears, MD, with the Alexander Fleming Award for Lifetime Achievement. Sears is a professor of medicine and oncology at the Johns Hopkins University School of Medicine and a professor of molecular microbiology and immunology at the university’s Bloomberg School of Public Health. Her many scientific discoveries have helped to describe how microbial communities residing in the gut influence immune responses that promote tumor development. Sears’ foundational work in understanding the microbiome’s role in cancer is critical to identifying biomarkers that can forecast cancer risk and may also lead to the development of therapeutic strategies tailored to an individual’s microbial makeup for more personalized treatment. Several institutes at NIH, including the National Cancer Institute, have supported her research. Since 2022, she’s been editor-in-chief of The Journal of Infectious Diseases.
American Pediatric Society honors Gelb Bruce D. Gelb, MD, is the recipient of the 2026 American Pediatric Society John Howland Award. The society bestowed its highest honor on Gelb in recognition of his contributions to advancing child health and the field of pediatrics. Gelb, a long-standing NIH awardee who has received grants from several institutes over the past 35 years, serves as a pediatric cardiologist and geneticist at the Icahn School of Medicine at Mount Sinai. He has characterized the genetic causes of congenital heart disease (CHD) and related disorders and has helped establish the molecular foundations of CHD. His identification of the first genetic cause of Noonan syndrome paved the way for understanding a broader group of developmental conditions known as the RASopathies, and so shaped how physicians diagnose, predict, and treat these disorders.
Happi’s Sentinel project receives MacArthur Foundation award The MacArthur Foundation is awarding $100 million to a private pandemic prevention network across Africa, a joint effort co-led by Pardis Sabeti, MD, PhD, of the Broad Institute and Christian Happi, PhD, of the Institute of Genomics and Global Health, Redeemer’s University, Nigeria. Sentinel, which has trained more than 3,000 public health workers from 53 of Africa’s 54 countries, builds directly on research conducted by Happi and supported by Fogarty and NIH through The Human Heredity and Health in Africa (H3Africa) program and the Data Science for Health Discovery and Innovation in Africa (DS-I Africa) Initiative. The MacArthur award will help expand Sentinel’s geographic reach over the next five years, creating a stronger system capable of alerting local communities — and the world — to previously undetected diseases. During his research career, Happi has investigated human infectious disease genomics and focused on host-pathogen interactions. In 2013, he helped establish the Institute of Genomics and Global Health with funding from the NIH.
Tarini tapped for Norman J. Siegel New Member Award The American Pediatric Society (APS) named Beth A. Tarini, MD, the 2025 Norman J. Siegel New Member Outstanding Science Award recipient for her contributions to pediatric science. Tarini serves as the Richard L. and Agnes F. Hudson Chair in Health Services Research and professor of pediatrics at George Washington University and Children’s National Hospital. Tarini’s clinical and research interests focus on genetic testing in pediatric care. She holds several leadership roles at her current institutions, including co-director of the Center for Translational Research, director of Resident Research at Children’s National, and director of academic development at the Goldberg Center for Community Pediatric Health. Tarini is a principal investigator on several Eunice Kennedy Shriver National Institute of Child Health and Human Development grants as well as one from National Institute of General Medical Sciences. Nov/Dec 2025
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FUNDINGNEWS On behalf of the Fogarty International Center at the U.S. National Institutes of Health (NIH), the following funding opportunities, notices, and announcements may be of interest to those working in the field of global health research.
Funding Announcement
SCAN
TO READ MORE
Deadline
Details
March 9, 2026
https://www.fic.nih.gov/Programs/Pages/ research-scientists.aspx
March 20, 2026
https://www.fic.nih.gov/Programs/Pages/ mhealth.aspx
August 6, 2026
https://www.fic.nih.gov/Programs/Pages/ infectious-disease.aspx
International Research Scientist Development Award (IRSDA)
(K01 Independent Clinical Trial Not Allowed) (K01 Independent Clinical Trial Required)
Mobile Health: Technology and Outcomes in Low and Middle Income Countries (mHealth)
(R21/R33 Clinical Trial Optional)
Global Infectious Disease Research (GID) Training Program (D43 Clinical Trial Optional)
Fogarty Fogarty International Center National Institutes of Health 31 Center Drive Bethesda, MD 20892
Advancing Science for Global Health
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Bridging the Gaps between Aspirin Guidelines and Pregnancy Outcomes Matthew K. Hoffman, M.D., M.P.H. Department of Obstetrics & Gynecology, Christiana Care
ABSTRACT Currently birth outcomes in the United States lag other industrialized countries and are driven predominantly by adverse pregnancy outcomes including preeclampsia, spontaneous preterm birth, stillbirth and fetal growth restriction. In aggregate these conditions are termed adverse pregnancy outcomes (APOs) and are complex in their origin, but largely reflect placentally mediated conditions that begin in early pregnancy. Low-dose aspirin (LDA) has been shown to lower the risk of APOs, but questions about the optimal dose, patient population to receive it, and barriers to prescribing and adherence have limited the impact of LDA on a population level. Multiple investigations unfortunately have shown that uptake is low and often biased in its provision. To address these inequities in care, the Delaware Perinatal Quality Collaborative (DPQC) organized efforts around standardizing screening all patients, providing hospital level feedback and enhanced patient education. With this effort, the rate of appropriate LDA prescription increased from 10% to 65%. Further studies and thoughtful conversations around additional barriers to care must be addressed jointly by researchers, providers, public health officials, patients and the community at large if the full promise shown in randomized controlled trials is to be realized.
CURRENT STATUS OF OBSTETRICAL OUTCOMES
LDA FOR THE PREVENTION OF PREECLAMPSIA
Little change has occurred in obstetrical outcomes in the last several decades, with most gains in outcomes being attributable to antenatal corticosteroids, improved neonatal care and guidelines limiting iatrogenic late preterm birth.1,2 In 2024, the March of Dimes deemed the US as having a grade of “D+” for preterm birth, noting that preterm birth rates have steadily increased, with the state of Delaware similarly receiving a D+.3 The predominant drivers of preterm birth are spontaneous preterm birth and iatrogenic delivery, mostly the result of preeclampsia, fetal growth restriction and maternal medical conditions associated with higher risks of stillbirth.
Given the importance of preeclampsia, increasingly efforts have pivoted to the prevention of preeclampsia. In 1978, three obstetricians in California published a case report in the Lancet of an individual who had repetitive cases of preeclampsia and poor outcomes followed by a successful pregnancy after being treated with daily low-dose aspirin.6 This case report study was followed up a year later by a case control study, wherein women delivering at a UK hospital were asked if they had taken aspirin in the prior fortnight, and those who did not have preeclampsia were more likely to report that they had been taking LDA.7
Of ongoing and growing concern is the issue of preeclampsia, which has been increasing across the United States over the last decade, approaching a rate of 1 in 10 pregnancies.4 This increase is thought to be the result of a birthing population that is getting older, having a higher body mass index, and having more associated medical disorders. From a mechanistic standpoint, the underlying causes of preeclampsia are increasingly being understood in that it is probably at least two separate disease processes that converge on a common phenotype of high blood pressure occurring after 20 weeks. Researchers have now begun to divide preeclampsia into two different forms of preeclampsia: early onset preeclampsia (EOPE) which occurs before 34 weeks, results in higher rates of fetal growth restriction, and more maternal/neonatal complications; and late onset preeclampsia (LOPE) which is comparatively benign with fewer maternal/neonatal complications.5 EOPE has been clearly associated with early placental development between 10 and 16 weeks while LOPE appears to be linked to metabolic stress on the placenta. 62 Delaware Journal of Public Health - December 2025
Subsequently, this has led to numerous randomized trials in both high and low-risk populations for the prevention of preeclampsia. To date, over 60,000 pregnancies have been randomized to LDA with a consistent treatment effect being seen that LDA lowers the overall rate of preeclampsia by approximately 10%.8,9 This effect appears to be greatest when LDA is begun before 16 weeks, a time of active placental development.10 Though these effects appear to be modest, when examined more closely, LDA has a profound reduction on the rate of EOPE (62% reduction prior to 34 weeks and 30% reduction in less than 37 weeks).11,12 This echoes the concept that LDA may only be effective if given before 16 weeks when poor placental development results in EOPE. It thus appears that the principal benefit of LDA may not be in the prevention of preeclampsia but rather in delaying its onset to a time frame when neonatal outcomes are markedly better.
LDA and Other APOs Though initially thought to be a preventative strategy for preeclampsia, others have put forward that other placentally mediated conditions such as preterm birth, fetal growth Doi: 10.32481/djph.2025.12.07
restriction, and still birth may be also lessened by LDA. Improvement in these outcomes has now been documented in meta-analyses and large trials.13,14 In 2020, Hoffman and colleagues published the ASPIRIN trial that randomized 11,976 nulliparous women with a singleton pregnancy to either aspirin 81 mg or placebo early in in pregnancy (6-14 weeks). This study not surprisingly found a decrease in overall preeclampsia (11%), preeclampsia before 34 weeks of 62% but also preterm birth less than 37 weeks (11%), preterm birth before 34 weeks (25%), stillbirth (14%), and fetal growth restriction associated with preeclampsia (88%); fundamentally confirming all the findings of the meta-analyses.9,11 Though these benefits have been shown consistently across trials, from a public policy standpoint LDA remains mostly focused as a preventative strategy for preeclampsia because of its near 50-year history of being framed as a preventative strategy for preeclampsia. If we are to improve birth outcomes, it will be important to continue to bring forward all of these potential benefits.
Dose and Adherence and its Impact on Birth Outcomes As a lingering question, the issue of dose has piqued the intrigue of investigators following the publication of the ASPRE trial that utilized a dose of 150mg.12 Both small prospective trials15 and meta-analyses10 have suggested that higher doses are more impactful in preventing poor outcomes. For example, a meta-analysis examining dose in low-risk women, found that the risk of preterm birth was markedly lower in women randomized to a dose of 100mg or greater (RR 0.39, 95% CI 0.31-0.48) compared to those randomized to a lower dose.16 Currently, several large trials are currently directly comparing higher doses (150mg162mg) vs. lower doses (75-81mg), which will hopefully further inform guidelines. In addition to the question of does is the question of adherence. In a large prospective RCT, Rolnik and colleagues found a lack of benefit when adherence was less than 90% (Rolnik et al., 2017). Unfortunately, typical use in clinical circumstances is often much lower than it is research trials.
BARRIERS TO REALIZING THE FULL BENEFIT OF LDA IN CLINICAL USE Inefficient Screening Guidelines One of the greatest challenges in realizing the benefits of LDA in clinical practice is the ability of screening guidelines to identify at risk pregnancies. Such guidelines can be cumbersome to implement in clinical care and provider uptake can be variable. The prior American College of Obstetricians and Gynecologists (ACOG) guidelines suggested that the detection rate was poor.17 In 2021, these guidelines were amended to consider LDA in pregnancies associated with low-socioeconomic status or in black pregnancies. These changes potentially result in over-half of US pregnancies being potentially eligible for LDA, and further analyses suggest that universal recommendations may be the most cost-effective strategy.18
Provider Behavior A second clear barrier is provider adoption. Vendelbo and colleagues in a study examining the behavior of providers following a 2012 guideline recommending LDA in highrisk pregnancies found that only 12% of at-risk pregnancies were receiving aspirin four years after the guidelines were implemented.19 Not surprisingly, the impact on perinatal outcomes was noted to be modest. Further complicating the issue, a number of studies have demonstrated that providers are frequently biased in their prescription of LDA, creating further barriers to achieving equity.20
Patient Factors Beyond both the screening guidelines and provider prescribing behavior, patient factors associated with low-rates of adherence have been well documented. From the literature, factors such as health literacy, lack of trust in the health care system, socioeconomic drivers (housing instability), lack of peer support, perceived risks and psychological factors have all been shown to affect adherence.21 Of particular concern for many pregnant people is the potential long-term effects on the newborn. This is in part triggered by the current FDA black-box warning about NSAIDs in pregnancy. Though the black box warning notes that 81mg of LDA is an exception, because of the warning, concerns for risk may be inferred. Nonetheless, well conducted follow-up trials have suggested no difference in either neurodevelopment or improved outcomes.22,23 It should be noted that LDA adherence is uniquely understudied, and if the promise of LDA is to occur on a population level understanding, patient factors and potential remedies must be undertaken. Key to this effort will be community engagement and listening to fully understand barriers. In addition, trialing potential solutions such as digital engagement,24 social media and other novel approaches must be undertaken.
Implementation in Delaware In the first quarter of 2021, the Delaware Perinatal Quality Collaborative (DPQC), which is composed of birth hospitals, birth centers, obstetrical providers, state government officials, insurance providers, and public advocates, agreed to take on an initiative to increase awareness and screening for LDA. It was agreed that all providers would routinely screen for LDA in all patients using a standardized screening tool. In addition, standardized education using a QR code would be provided. Key to this effort was engaging all obstetrical providers in the state, educating them on the benefits of LDA, and listening to their suggestions to improve uptake and recognition amongst at risk pregnancies. Meetings were held both at departmental levels and individual practices with episodic return visits to understand how the provided tools were being utilized. Each hospital agreed to ask all patients if they were prescribed LDA during their pregnancy and quarterly audits of 20 charts were made. Each hospital or birth center were provided feedback on their compliance with the recommendations. From a baseline rate of 10% of at-risk pregnancies being prescribed, this rate increased quickly and showed sustained uptake to a rate of approximately 68% (figure 1). 63
Figure 1. Appropriate Low Dose Aspirin Prescriptions in At-Risk Pregnancies Over Time in Delaware
CONCLUSION Currently, birth outcomes in the United States and Delaware lag behind our hopes and aspirations. Though complex in its origins, LDA offers at least a partial remedy to improving outcomes. By engaging joint efforts of providers, government, and insurers through the DPQC, the rate of appropriate LDA prescription was able to be markedly improved. Nonetheless, to realize the potential, researchers must continue to investigate the optimal dose of LDA, as well as conduct implementation research studies to understand the barriers to perfect care for both providers and patients. Key to this will be to engage both patients and communities in these discussions to co-develop solutions and, in turn, better outcomes.
FINANCIAL DISCLOSURE Dr. Hoffman is currently an MPI of the NICHD-funded ADEPT trial. This project was completed without external funding. Dr. Hoffman may be contacted at mhoffman@christianacare.org.
2. Richardson, D. K., Gray, J. E., Gortmaker, S. L., Goldmann, D. A., Pursley, D. M., & McCormick, M. C. (1998). Declining severity adjusted mortality: Evidence of improving neonatal intensive care. Pediatrics, 102(4 I), 893–899. https://doi.org/10.1542/peds.102.4.893 3. March of Dimes. (n.d.). 2025 March of dimes report card For United States. PeriStats. Retrieved from https://www.marchofdimes.org/peristats/reports/united-states/report-card 4. Ayyash, M. K., McLaren, R., Jr., Shaman, M., & Al-Kouatly, H. B. (2024, July 9). Trends in preeclampsia risk factors in the US From 2010 to 2021. JAMA, 332(2), 167–169. https://doi.org/10.1001/jama.2024.8931 5. Jung, E., Romero, R., Yeo, L., Gomez-Lopez, N., Chaemsaithong, P., Jaovisidha, A., . . . Erez, O. (2022, February). The etiology of preeclampsia. American Journal of Obstetrics and Gynecology, 226(2S), S844–S866. https://doi.org/10.1016/j.ajog.2021.11.1356 6. Goodlin, R. C., Haesslein, H. O., & Fleming, J. (1978, July 1). Aspirin for the treatment of recurrent toxaemia. Lancet, 312(8079), 51. https://doi.org/10.1016/S0140-6736(78)91367-3
REFERENCES
7. Crandon, A. J., & Isherwood, D. M. (1979, June 23). Effect of aspirin on incidence of pre-eclampsia. Lancet, 313(8130), 1356. https://doi.org/10.1016/S0140-6736(79)91996-2
1. Crowley, P. A. (1995, July). Antenatal corticosteroid therapy: A meta-analysis of the randomized trials, 1972 to 1994. American Journal of Obstetrics and Gynecology, 173(1), 322–335. https://doi.org/10.1016/0002-9378(95)90222-8
8. Duley, L., Meher, S., Hunter, K. E., Seidler, A. L., & Askie, L. M. (2019, October 30). Antiplatelet agents for preventing pre-eclampsia and its complications. Cochrane Database Syst Rev, 2019(10), CD004659. https://doi.org/10.1002/14651858.CD004659.pub3
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9. Hoffman, M. K., Goudar, S. S., Kodkany, B. S., Metgud, M., Somannavar, M., Okitawutshu, J., . . . Derman, R. J., & the ASPIRIN Study Group. (2020, January 25). Low-dose aspirin for the prevention of preterm delivery in nulliparous women with a singleton pregnancy (ASPIRIN): A randomised, double-blind, placebo-controlled trial. Lancet, 395(10220), 285–293. https://doi.org/10.1016/S0140-6736(19)32973-3
17. O’Gorman, N., Wright, D., Poon, L. C., Rolnik, D. L., Syngelaki, A., de Alvarado, M., . . . Nicolaides, K. H. (2017, June). Multicenter screening for pre-eclampsia by maternal factors and biomarkers at 11-13 weeks’ gestation: Comparison with NICE guidelines and ACOG recommendations. Ultrasound Obstet Gynecol, 49(6), 756–760. https://doi.org/10.1002/uog.17455
10. Roberge, S., Bujold, E., & Nicolaides, K. H. (2018, May). Meta-analysis on the effect of aspirin use for prevention of preeclampsia on placental abruption and antepartum hemorrhage. American Journal of Obstetrics and Gynecology, 218(5), 483–489. https://doi.org/10.1016/j.ajog.2017.12.238
18. Wheeler, S. M., Myers, S. O., Swamy, G. K., & Myers, E. R. (2022, January 4). Estimated prevalence of risk factors for preeclampsia among individuals giving birth in the US in 2019. JAMA Network Open, 5(1), e2142343–e2142343. https://doi.org/10.1001/jamanetworkopen.2021.42343
11. Kavi, A., Hoffman, M. K., Somannavar, M. S., Metgud, M. C., Goudar, S. S., Moore, J., . . . Derman, R. J. (2023, November). Aspirin delays the onset of hypertensive disorders of pregnancy among nulliparous pregnant women: A secondary analysis of the ASPIRIN trial. BJOG, 130(Suppl 3), 16–25. https://doi.org/10.1111/1471-0528.17607
19. Vendelbo, J. H., Thunbo, M. Ø., Henriksen, T. B., Liew, Z., Larsen, A., & Pedersen, L. H. (2025, July 7). The nationwide impact of guidelines for prophylactic aspirin treatment for preeclampsia. Paediatric and Perinatal Epidemiology. https://doi.org/10.1111/ppe.70046
12. Rolnik, D. L., Wright, D., Poon, L. C., O’Gorman, N., Syngelaki, A., de Paco Matallana, C., . . . Nicolaides, K. H. (2017, August 17). Aspirin versus placebo in pregnancies at high risk for preterm preeclampsia. The New England Journal of Medicine, 377(7), 613–622. https://doi.org/10.1056/NEJMoa1704559 13. Roberge, S., Nicolaides, K. H., Demers, S., Villa, P., & Bujold, E. (2013, May). Prevention of perinatal death and adverse perinatal outcome using low-dose aspirin: A meta-analysis. Ultrasound Obstet Gynecol, 41(5), 491–499. https://doi.org/10.1002/uog.12421 14. Roberge, S., Sibai, B., McCaw-Binns, A., & Bujold, E. (2016, July). Low-dose aspirin in early gestation for prevention of preeclampsia and small-forgestational-age neonates: Meta-analysis of large randomized trials. American Journal of Perinatology, 33(8), 781–785. https://doi.org/10.1055/s-0036-1572495 15. Amro, F. H., Blackwell, S. C., Pedroza, C., Backley, S., Bitar, G., Daye, N., Bartal, M. F., Chauhan, S. P., & Sibai, B. M. (2025). Aspirin 162 mg vs 81 mg for preeclampsia prophylaxis in high-risk obese individuals: a comparative effectiveness open-label randomized trial (ASPREO). American Journal of Obstetrics and Gynecology, 232(3), 315.E1-315.E8. https://doi.org/10.1016/j.ajog.2024.06.038 16. Wodoslawsky, S., Khanuja, K., Saccone, G., Hoffman, M. K., & Berghella, V. (2025, February). Low-dose aspirin use in low-risk nulliparous pregnancies: A systematic review and meta-analysis of randomized controlled trials. American Journal of Obstetrics & Gynecology MFM, 7(2), 101595. https://doi.org/10.1016/j.ajogmf.2024.101595
20. Jones Pullins, M., Boggess, K., & Porter, T. F. (2023, December 1). Aspirin in Pregnancy. Obstetrics and Gynecology, 142(6), 1333–1340. https://doi.org/10.1097/AOG.0000000000005429 21. Peh, K. Q. E., Kwan, Y. H., Goh, H., Ramchandani, H., Phang, J. K., Lim, Z. Y., . . . Thumboo, J. (2021, September). An adaptable framework for factors contributing to medication adherence: Results from a systematic review of 102 conceptual frameworks. Journal of General Internal Medicine, 36(9), 2784–2795. https://doi.org/10.1007/s11606-021-06648-1 22. Hoffman, M. K., Goudar, S., Dhaded, S., Figueroa, L., Mazariegos, M., Krebs, N. F., . . . Derman, R. J. (2024, April 1). Neurodevelopment of children whose mothers were randomized to low-dose aspirin during pregnancy. Obstetrics and Gynecology, 143(4), 554–561. https://doi.org/10.1097/AOG.0000000000005514 23. Zhu, J., Gan, Y., Yang, C., Gu, W., Wang, Y., Zhang, J., & Liu, Z. (2024, November). In utero aspirin exposure and child neurocognitive development: A propensity score-matched analysis. BJOG, 131(12), 1630–1639. https://doi.org/10.1111/1471-0528.17871 24. Santosa, A., Juniarti, N., Pahria, T., & Susanti, R. D. (2025, November 21). Digital adherence technology to improve medication adherence in tuberculosis patients: A systematic review and meta-analysis randomized control trials. NPJ Primary Care Respiratory Medicine, 35(1), 52. https://doi.org/10.1038/s41533-025-00457-3
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The Role of Health Education in Maternal and Infant Health Adrienne Palmer, M.S., C.L.S. Nemours Children’s Health
ABSTRACT Maternal and infant health outcomes in the United States remain concerning despite advances in medicine, with persistent disparities in underserved communities. This article highlights the role of health education as a preventive strategy to improve outcomes for mothers and babies. By providing expectant and new parents with knowledge on prenatal care, nutrition, breastfeeding, infant safety, and postpartum wellness, health education programs empower families to make informed decisions and adopt healthier practices. Drawing on professional experience in maternal and infant nutrition and health education, the article introduces Healthy from the Bump, a tailored program designed to provide culturally relevant, accessible, and practical education for parents and their support partners. While immediate results may be difficult to measure, health education’s long-term benefits include reducing risks, fostering healthier habits, and strengthening caregiver confidence. Investing in maternal and infant health education is an essential step toward closing health gaps and building healthier generations from the very start.
INTRODUCTION Improving maternal and infant health shouldn’t be such a hot topic in the United States, but with 669 maternal deaths in 2023 and 20,500 infant deaths in 2022, it needs to be.1,2 Despite advances in medicine, maternal and infant health outcomes continue to fall short, especially in underserved communities. But there is a powerful, often overlooked tool that can help improve those outcomes: health education. Yes, some causes of maternal and infant deaths are outside the scope of health education. However, maternal and infant health education programs can help improve health outcomes, by reducing prematurity and low birth weight, and increasing positive health behaviors and breastfeeding initiation rates.3
WHAT IS MATERNAL AND INFANT HEALTH EDUCATION? Maternal and infant health education entails providing expectant and new parents with information, skills, and support to promote healthy pregnancies, safe childbirth, and positive outcomes for both mothers and babies. This type of education covers a wide array of topics including the importance of prenatal care, maternal and infant nutrition, breastfeeding, infant safety and wellness, and postpartum care. Programs should be tailored to the audience’s cultural and personal needs, since this will increase their understanding and engagement with the material.4 The goal is to empower parents with the knowledge they need to make informed decisions, reduce health risks, and feel confident about caring for themselves and their infants.
CREATING THE HEALTHIEST GENERATIONS OF CHILDREN Nemours Children’s Health is on a mission to create the healthiest generations of children. I believe that healthy children start with healthy parents and healthy pregnancies. 66 Delaware Journal of Public Health - December 2025
When the Community Health Education team at Nemours Children’s was first created, we dove headfirst into creating curriculums for children. But we soon learned that we could provide all the health education in the world to the children, but unless we educated their caregivers too, some of it would be lost. Prior to joining Nemours, I worked for the Women, Infants, and Children (WIC) program in three different states over five years, and held a variety of nutrition-focused positions. Between my experience there and my career change into health education, I realized that there was a huge health information gap with parents, whether they are first time parents or experienced several times over.
HEALTHY FROM THE BUMP I wanted to create a health education program that encompassed maternal and infant health information that was accessible to everyone. I researched topics that moms said they wished they knew more about before giving birth, and created a series of sessions that focused on staying healthy during pregnancy, breastfeeding basics, infant nutrition, infant wellness, infant safety, and postpartum care. Each session came with an incentive to support the topic, like a hand pump, baby’s first cup, and postpartum self-care items. These sessions were designed to be in small group settings to build trust among the parents, encourage sharing, and improve learning. I also wanted to include a support partner for each parent, so the people supporting them could learn the same information. After months of researching and building the program, Healthy from the Bump was born.
THE FUTURE OF MATERNAL AND INFANT HEALTH EDUCATION The future of maternal and infant health education lies in creating more accessible, inclusive, and tailored learning opportunities for all families. As healthcare systems begin to focus more on prevention, health education programs can be Doi: 10.32481/djph.2025.12.08
delivered in a multitude of ways: digital platforms, community outreach, and culturally tailored programs that meet parents where they are. While most health education programs don’t have immediately measurable outcomes, their long-term impact is significant, shaping healthier habits, reducing risks, and improving quality of life for mothers and babies. By combining evidence-based information with community-centered approaches, maternal and infant health education can help close gaps in health outcomes and ensure that every mother and baby is Healthy from the Bump. Ms. Palmer may be contacted at Adrienne.palmer@nemours.org.
REFERENCES 1. Hoyert, D. L. (2025). Health E-Stat 100: Maternal mortality rates in the United States, 2023. https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2023/Estat-maternal-mortality.pdf 2. Centers for Disease Control and Prevention. (2024). Infant mortality. https://www.cdc.gov/maternal-infant-health/infant-mortality/index.html 3. Herval, A. M., Oliveira, D. P. D., Gomes, V. E., & Vargas, A. M. D. (2019, June). Health education strategies targeting maternal and child health: A scoping review of educational methodologies. Medicine, 98(26), e16174. https://doi.org/10.1097/MD.0000000000016174 4. Lapinski, M. K., Oetzel, J. G., Park, S., & Williamson, A. J. (2025, May). Cultural tailoring and targeting of messages: A systematic literature review. Health Communication, 40(5), 808–821. https://doi.org/10.1080/10410236.2024.2369340
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Global Mapping of Evidence on Vaccination Related Education Through School Based Curriculum: A Systematic Scoping Review Bhupender Singh Khanuja John Snow India Private Limited, India
Shipra Verma Immunization Technical Support Unit, India
Palak Badhwar United Nations Development Programme, India
Anjori Agrawal United Nations Development Programme, India
Kapil Singh United Nations Children’s Fund, India
Ashwani Verma United Nations Development Programme, India
ABSTRACT Background: Educating school children about vaccination as a part of health promotion intervention is one of the strategies to improve vaccination acceptance. The aim of this scoping review is to describe the range of schoolbased education interventions related to vaccination and particularly about efforts to include such education in school curricula. Methods: This systematic scoping review was conducted based on the methodological framework proposed by Arskey and O’Malley. Searches were performed in four databases from Nov 1, 2004 to Nov 30, 2024. Databases were systematically searched for published articles on school education on vaccination. Two independent authors screened the articles followed by data extraction using MS-Excel tool. Results: Out of total identified 18,706 articles, only six articles met the inclusion criteria. All studies were focused on developed countries and most were experimental studies. Interventions were delivered by teachers or researchers and reported general improvements in vaccine knowledge as well as of vaccine-specific interventions. This review documented the outcomes on a curriculum based on immunity and vaccine related concept in school education. The review also highlights the ad hoc approach of health promotion during the vaccine specific knowledge dissemination in school. Conclusion: Formalizing health education could be a long-term strategy for better public health outcomes which face numerous challenges due to vaccine hesitancy or denial. Structured school curriculum on vaccination is warranted to sustain the knowledge on vaccination and its effect on community.
INTRODUCTION Vaccination has played a pivotal role in advancing public health, leading to the complete eradication of smallpox and the near elimination of poliomyelitis, with only a few countries still reporting cases.1 It is estimated that immunization programs prevent between 3.5-5 million deaths annually by protecting against diseases such as diphtheria, tetanus, pertussis (DPT), and measles.2 Furthermore, vaccination contributes to the prevention of numerous future fatalities among older populations, exemplified by hepatitis B immunization, which is projected to avert approximately 600,000 deaths each year.3 Recently, as a response to the COVID Pandemic, COVID vaccination has saved an estimated 2.5 million lives globally and 14.8 million life years.4 This is partly due to the growing number of infectious diseases that are now recognized as preventable through vaccination. In 1978, the World Health Organization (WHO) launched the Expanded Programme on Immunization (EPI) focusing on preventing children from vaccine preventable diseases (VPDs).5 Beginning in 1978, India introduced the first national immunization programme, which has made significant strides in ensuring that children and pregnant women are protected against VPDs. The Universal Immunization Programme (UIP) was introduced in 1985 and designed to provide comprehensive vaccination coverage for all children and pregnant women across the country.6 68 Delaware Journal of Public Health - December 2025
With the introduction of new vaccines such as DPT, Hepatitis B Vaccine, Haemophilus Influenzae type B (Hib), Polio, MeaslesRubella Vaccine, Pneumococcal Conjugate Vaccine, Rotavirus Vaccine, and the Human Papillomavirus Vaccine against vaccinepreventable diseases, mostly across developing countries such as India, Bangladesh, Nepal, Maldives, Bhutan, DPR Korea, Bhutan, Maldives, Timor-Leste and Sri Lanka, and improvements in vaccine coverage, a larger cohort of population has been protected against a wider range of infectious disease, and has eliminated smallpox, polio, maternal and neonatal tetanus, and measles-rubella.7,8 With these advancements, vaccination has the capability to achieve the Sustainable Development Goal (SDG) Target 3.b: “Support the research and development of vaccines and medicines for the communicable and non-communicable diseases that primarily affect developing countries, provide access to affordable essential medicines and vaccines” in alignment with the Immunization Agenda 2030.9,10 Despite these efforts, nearly 14.5 million children globally missed out any vaccination: zerodose children.11 The global coverage of first dose of a measles vaccine has seen a reduction to 83% in 2023, down from 86% in 2019, DPT-3 coverage stood at 84%, and HPV Vaccine coverage in girls was 27% in 2023.11 Low-to-middle income countries such as India continue to face challenges in reaching the target of “leaving no child behind” and ensuring child immunization coverage of 90% or greater.12 However, recent data from the WHO Doi: 10.32481/djph.2025.12.09
and Unicef Estimates of National Immunization Coverage (WUENIC) report reveals a concerning 2% increase in the number of zero-dose children in India, indicating a severe immunity gap within the community.13 Additionally, outbreaks of diseases like measles and diphtheria have been reported in certain regions, highlighting the gaps that persist in immunization coverage. A significant barrier to achieving universal immunization is vaccine hesitancy and avoidance.14 Vaccine refusal, particularly in rural and underserved areas, has become a growing concern. Vaccine hesitancy is a complex issue influenced by various factors, including misinformation, cultural beliefs, and a lack of understanding about vaccine safety and efficacy.15 Learnings from a recent COVID-19 vaccination programme in India which administered 220 vaccine doses during pandemic paved a strengthened way for life course immunization across the globe.16 However, addressing vaccine hesitancy requires continued effort, including understanding the perceptions of vaccine-refusing communities and improving their knowledge about the benefits of immunization. In recent years, various strategies have been implemented to address the challenges of vaccine hesitancy within communities to improve vaccination demand, with a particular focus on health promotion services provided through schools.17–19 Evidence from multiple countries reported the uptake of school-based programs for multiple public health issues such as nutrition education,20 oral health programs,21 diet and sugar supplementation, school feeding, and school education.20 School curriculum can also be utilized to instill knowledge of benefits of vaccines through health education, thereby increasing demand of vaccine in the community. With this background, we wanted to summarize the global evidence available which utilized the school-based curriculum as a platform for vaccination education among school going children population in an effective way.
METHODS Objective The purpose of this review is to examine the various interventions designed to increase the knowledge and awareness of school going children, parents and teachers through school-based curriculum regarding the benefits of vaccination, as well as to summarize the component of the interventions. Additionally, the paper also explored the efforts made to integrate this knowledge into formal educational content, either as part of the curriculum or through teacher training programs. We followed the Arksey and O’Malley’s framework, which has been further refined in accordance with Levac, et al. and the Joanna Briggs Institute.22 As per the Arksey and O’Malley’s framework, the five stages for conducting a scoping review are: 1. Identification of research question 2. Identifying relevant studies 3. Study selection 4. Charting the data 5. Collating, summarizing and reporting the results
Stage 1: Identification of the Research Question All team members (BK, KS, PB and AV) were involved in the brainstorming sessions for identification and finalizing the research question. As per the terminologies addressing school health programmes for vaccination, the following research questions were developed: • Descriptives How much evidence is available to enhance the knowledge and awareness of children, teachers, and parents in schools about vaccines and vaccination? Where is the evidence available as per WHO region classification? • Population/Study Design What are the characteristics of the targeted populations? What are the study designs and research methods used for generating evidence on improving knowledge and awareness in schools on vaccines and vaccination? • Interventions What type of interventions are documented for enhancing knowledge and awareness in schools on vaccines and vaccination among stakeholders? What is the duration of these interventions? • Comparators What are the characteristics of the comparator group (if any)? • Outcomes What are the outcomes of such interventions in terms of knowledge and awareness about vaccines and vaccination among study population? Additionally, this scoping review also documents any attempts made to make such knowledge content formalized as a part of curriculum or training.
Stage 2: Identifying Relevant Studies As per the Arksey and O’Malley’s framework, this stage includes the identification of available evidence. The search was conducted in accordance with Medical Subject Heading (MeSH) terms and associated keywords. The search strategy was developed in consultation with a subject matter expert and included a wide reach of relevant keywords. A search query (table 1) was developed for PubMed and was reciprocated in other databases such as Scopus, Web of Science, and EBSCOhost. These databases were selected due to accessibility through authors’ organizations and were comprehensive in including information on school health programmes for vaccination. The search was carried out on December 3, 2024 for the period from November 1, 2004 to November 30, 2024. Only English language literature was included in this scoping review. The reference list of included studies was also searched for potential inclusion. 69
Table 1. PubMed Based Search Strategy Search No.
Search Strategy
#1
Students OR School student OR school children OR child OR children OR teacher OR adolescent OR parents OR mother OR father OR school OR college OR young adult
#2
Vaccine OR Vaccines OR vaccination OR immunization OR immunization drive OR immunization campaign OR schoolbased vaccination OR adolescent vaccination OR vaccination programme OR vaccination training OR vaccination programme curriculum OR vaccination programme curricula OR vaccination chapter OR vaccination textbook
#3
Global OR all countries
#4
#2 and #3
#5
#1 and #4
Items and Search Terms • Population: Students, school student, school children, child, children, teacher, adolescent, parents, mother, father, school, college, young adult • Concept: Vaccine, vaccines, vaccination, immunization, immunization drive, immunization campaign, school-based vaccination, adolescent vaccination, vaccination programme, vaccination training, vaccination programme curriculum, vaccination programme curricula, vaccination chapter, vaccination textbook • Context: Global, all countries Inclusion Criteria 1. Primary studies related to higher classes or vaccine specific publications (i.e., HPV vaccine) were included. 2. Interventions in school students, teachers, and/or parents related to their knowledge enhancement for vaccines or vaccination were included. 3. Efforts to increase the knowledge of the students/teachers/ parents on vaccination during the program interventions were also made part of this review. 4. Only English language literature are included in this review. Exclusion Criteria 1. Secondary studies, books, case studies, conference material and dissertations were excluded.
Stage 4: Charting the Data An MS-Excel based data extraction tool was developed in consultation with all five authors. Extracted information included study title, authors, publication year, country as per WHO Region classification, journal name, purpose, methods and study population, age group (if given), study design, sampling method, sample size, intervention, mode and frequency of intervention, comparison group, outcome relation to knowledge and awareness about vaccines and vaccination. Specific data were extracted independently by two authors (AV and BK) from full-text articles included in the final sample. Disagreements between reviewers were handled by consensus and, when agreement was not reached, a final decision was made by a third author (AA). Due to the heterogeneity of the study methods, populations and objectives, meta-analysis was not appropriate for this review. Critical Appraisal All studies were critically appraised through Joanna Briggs’s critical appraisal tool by two independent authors (AV and KS). The disagreements were resolved by the third author (BK).
Stage 5: Collating, Summarizing and Reporting the Results From the findings of included studies, the narratives and descriptive summaries were developed in the report formats based on the JBI reviewer manual recommendation. The summary tables were developed to study characteristics such as study design, sample size, intervention components etc. Other vital and relevant findings were also presented in the tabular format with suitable charts.
RESULTS
2. Studies in school related to program interventions like vaccination which do not have any component of knowledge enhancement of student, teacher or parent were excluded.
The search from multiple searches resulted in 18,706 studies. Based on our eligibility criteria, 18308 studies were screened through title and abstract screening and 25 studies were screened through full text screening (figure 1).
3. Vaccine or vaccination related studies not related to school students’ knowledge enhancements were excluded.
Study Characteristics
Stage 3: Study Selection The identified studies were exported to the Rayyan.ai software. These studies were screened at two stages. A title and abstract (Ti-Ab) screening by BK and AA, and full text screening done independently by PB and AV. Disagreements on inclusion/ exclusion at the Ti-Ab and full text screening stage were resolved through arbitration by a third author (PB and KS, respectively). The study selection and screening process is summarized in figure 1. 70 Delaware Journal of Public Health - December 2025
Table 2 summarizes the characteristics of the included studies based on the country, domain of the study area, and the primary objective of the study. All included studies were conducted in developed or high-income countries based on the world bank classification: three studies were conducted in USA and Canada, one each in Europe (France) and The Netherlands, and a single study in Australia.29 Interventions based on HPV vaccination was the domain of focus on two studies, multiple vaccination in a single study, and viral infection and Hep B vaccination was a focus area in other studies.
Figure 1. PRISMA Flow Chart of Study Identification
Screening
Identification
Identification of studies via databases Records identified from*: Databases (n = 18706) PubMed (n = 10047) Scopus (n = 3574) Web of Science (n = 3012) EBSCOhost (n = 2075)
Records removed before screening: Duplicate records removed (n = 541) Records marked as ineligible by automation tools (n = 0) Records removed for other reasons (n = 127)
Records screened (n = 18038)
Records excluded (n = 17997)
Reports sought for retrieval (n = 41)
Reports not retrieved (n = 16)
Reports assessed for eligibility (n = 25)
Included
Reports excluded: Records or study design (n = 19)
Studies included in review (n = 6)
71
Table 2. Study Characteristics Study ID
Country
WHO Region
Study focus domain
Study Objective
Bocquier et al23
France
EURi
HPV
To describe the development process of the Pre HPV intervention using the Guidance for reporting of intervention Development framework as a guide.
Gargano et al24
USA
AMRii
Adolescent vaccinationTdap, HPV, MCV4 and Influenza Vaccine
To determine the effectiveness of two interventions designed to enhance adolescent vaccination rates among a sample of adolescents attending middle or high schools.
Vaccination
To raise middle school student awareness, attitudes, and proactive behaviors about immunization, and to increase immunization rates among middle school students through implementation of a comprehensive integrated immunization promotion curriculum (Immunization Plus!)
Glik et al25
USA
AMR
Broman et al26
Canada
AMR
HPV Vaccine
To identify opportunities for HPV vaccine education in BC School-based immunization programs by exploring the perspectives of students, parents, school staff, and public health nurses on current School-based immunization programs.
Shocker et al27
The Netherlands
EUR
Viral Infection
To study to what extent Viruskenner- International education module creates conditions in which empowerment processes can arise and take place.
Skinner et al28
Australia
WPRiii
Hepatitis B vaccination
To evaluate a specifically designed hepatitis B Educational promotion curriculum package as part of a successful hepatitis B vaccination delivery system to adolescents.
The European region iiThe region of the Americas iiiWestern Pacific region
i
Table 3. Study Methodology Study ID
Study design
Study duration
Study population
Age group
Participant gender
Sampling method
Sample size
Bocquier et al
Mixed Methods design
16 months
Adolescents attending middle schools
11 to 14 years
NA
NA
17
Gargano et al
3-Armed Randomized Control Trial
24 months
Adolescents
Adolescents
Both
Randomization
667 middle school 401 high school students
Glik et al
Quasi experimental study
24 months
Middle school students
10 to 12 years
Both
Non-equivalent comparison-groups design with a lagged baseline component
678 students from 48 classroom in 22 schools
Broman et al
Qualitative study with Semi structured Focus Group Discussion
7 months
Grade six student
11–12 years
All
Purposive sampling
80 participants; 49 students
Shocker et al
Qualitative study
3 months
Students
11-12 years
Both Male and Female
NA
10 Students from 2 primary schools
Skinner et al
Randomized Controlled Study
NA
Adolescents and Schools
7 years
Both Male and Female
Randomization
925 students from 48 schools
72 Delaware Journal of Public Health - December 2025
Table 4: Intervention Characteristics Study ID
Intervention
Mode of Delivery
Bocquier
Educational group sessions on HPV infections and vaccination
Online information group session using eHealth tools, videos, serious video games
Gargano
A science teacher–delivered intervention targeted to students. Information about how tetanus, diphtheria, pertussis, meningitis, influenza, and human papillomavirus
Glik
Immunization Plus! Curriculum including Immunization Day video Experimental conditions: (a) training of teachers in the curriculum followed by curriculum implementation; (b) curriculum implementation, without teacher training; (c) screening of the Immunization Day video as the only intervention; and (d) no intervention.
Curriculum conditionIn classroom
Broman
NA
Focus group discussion
Shocker
Module which is implemented in a class for viral infection prevention
Semi structured interviews
Hepatitis B education/ promotion kit
Teachers were provided with specific resource information and autonomy in teaching was encouraged. Specific teacher training was offered.
Skinner
Class room teaching and questionnaire
Study Methodology Table 3 provides a summary of the characteristics of the studies included.
Study Design and Duration Among them, two studies follow a randomized study design, while two others adopt a qualitative study design. Additionally, one study employs a mixed-methods approach, and another is a quasi-experimental study. The duration of the studies varies significantly, ranging from 3 months to 24 months. Specifically, studies conducted by Gargano24 and Glik25 lasted 24 months,
Frequency
Once
Once
Comparison
Intervention Description
NA
Development multicomponent intervention including e health tools for students on HPV infection and vaccination and parents for promoting HPV vaccination.
Standard care
Education intervention materials include: Threat (HBM) * Perceived susceptibility to disease * Perceived severity of disease Expectations (HBM) * Perceived benefits of vaccination * Perceived barriers to vaccination Cues to Action (HBM) * Social/Peer influences * Media, disease symptoms Self-Efficacy for Vaccination (HBM) Social Norms (TRA) * Injunctive norms * Descriptive norms Total 5 thematic modules were developed: Communicable disease, Immunizations, the immune system, herd immunity, and personal and community responsibility of health. Information to young adolescents, their parents, and teachers about up-to-date adolescent immunization recommendations.
Once10 to 12 hours of classroom
Non-equivalent comparison groups
NA
NA
This study was conducted to identify opportunities for HPV Vaccine education.
NA
VIRUSKENNER: 8-week module added in a curriculum consisting of a lecture to identify health risks and to develop an intervention to prevent a virus infection
458 intervention students and 467 control students
Curriculum-based school health programs- Hepatitis B education/ promotion kit which had 4 lessons, delivered to all year 7 students over the weeks leading to the first immunization. Teaching activities include resource factsheet, and an information video. Parents were accessed through homework assignment.
Once
Over the weeks
while Bocquier23 reported a duration of 16 months, Broman26 reported 7 months, and Shocker27 reported 3 months. Skinner28 did not specify its study duration.
Study Population Most of the studies were conducted among adolescent populations, with the exception of the study by Skinner, which included participants as young as seven years old. Almost all studies also involved parents. Many studies included both male and female participants, although Bocquier, did not specify any gender. 73
Sample Size The sample size varied considerably, ranging from 10 participants (Shocker) to 925 participants (Skinner).
Intervention Characteristics Interventions were largely focused on improving the knowledge about the infections, their prevention, and vaccination (five studies); a single study was focused on identifying the opportunities for HPV Vaccine education. Five studies delivered the intervention face to face in school through teachers, and a single study delivered the intervention online through group sessions. Standard care or no intervention were provided among control groups in the studies conducted by Gargano,24 Glik,25 and Skinner.28
Intervention Description Bocquier23 developed a multifaceted intervention that included a handbook providing information on HPV infection and vaccination, complemented by an e-health platform featuring educational videos and interactive video games. Gargano24 employed the Health Behavior Model to assess factors influencing vaccination decisions, including perceived susceptibility and severity of diseases, benefits and barriers to immunization, and the role of peers, media, and societal influences in the context of tetanus, diphtheria, pertussis, meningitis, influenza, and HPV vaccines. Glik25 designed a classroom-based curriculum encompassing topics such as communicable diseases, immunization, the immune system, herd immunity, and individual and community health responsibilities. Similarly, Shocker27 developed educational modules delivered through classroom instruction, aimed at identifying health risks and preventing viral infections. Skinner28 implemented an educational
initiative focused on Hepatitis B awareness, integrating immunization promotion through informational videos presented in school settings (table 4).
Outcomes Measured Most studies evaluated the school going children’s (aged 7 to 14 years) knowledge and attitude for diseases and vaccination, and improved vaccination coverage and health behaviors. The study conducted by Shocker27 reported the need for empowering the adolescents through involvement in identifying health risks (table 5).
DISCUSSION Embedding vaccination education into school curricula as a long-term, sustainable strategy to address vaccine hesitancy and promote community-level demand for upcoming generations leads to intergenerational effects and making traditional ways (IEC, BCC, etc.) of demand less resource intensive. Educating children on immunity and vaccines at an early age can shape their lifelong health behaviors and position them as “vaccine messengers” in their communities. As these children grow into parents, their foundational knowledge can positively influence immunization decisions for the next generation—a lifecycle approach with both immediate and long-term benefits. While health education has long been a core component of health promotion strategies, immunization-specific education targeted at school students remains limited. This scoping review summarized the evidence on health promotion interventions for immunization targeting school going children and adolescents. Of the 14 studies reviewed, only six studies directly addressed school-based vaccination education; the remaining eight focused on vaccine education for other target groups such as pediatricians, medical
Table 5. Outcome Characteristics Study ID
Primary Outcome
Secondary Outcomes
Bocquier
Adolescents knowledge, attitude and intention to get vaccinated
The development process of the PrevHPV school-based and primary care-based multicomponent intervention aimed at improving HPV vaccine coverage amongst French adolescents.
Gargano
Development of a theory based intervention to increase adolescent vaccination rates among middle and high school students
Increase vaccine-related knowledge and positive attitudes regarding vaccination among students and parents
Glik
Curriculum improved knowledge attitude of students
Knowledge about immunizations and communicable diseases. Attitude towards immunization. Improved Health-related behaviors
Broman
Adolescent students valued a SBIP curriculum that integrated their perspectives, met their needs, and engaged them.
The introduction of age-appropriate and fun learning resources for students was identified as a useful opportunity to improve vaccine knowledge. The following themes were emerged: Theme 1: making SBIP curriculums student-centered Theme 2: adopting a collaborative and interdisciplinary approach to vaccine education Theme 3: actualizing parent education opportunities
Shocker
Viruskenner is successful in creating the conditions needed for empowerment, processes to arise and take place to improve health behavior.
Involvement of students played a role in identifying health risks and how they preferred to approach and fulfil the assignment. A participatory setting and community involvement appeared to be the most important empowering elements in this education module. Viruskenner may contribute to improving health behaviour with regards to prevention of virus infections.
Skinner
Increased student knowledge about hepatitis B and more favourable attitude to vaccination did not have a significant effect on the uptake of vaccine.
The findings of this study indicate that a more comprehensive delivery strategy is required.
74 Delaware Journal of Public Health - December 2025
and nursing students, and were thus excluded. The six relevant studies varied significantly in their approach but collectively represent the limited availability of literature directly engaging schools as a platform for strengthening immunization demand. A study was conducted by Golan, et al30 in 2018 in Israel delivered a universal wellness program through either a school-based setting or an out-of-school setting, which is comparable to the health promotion interventions which were delivered through both classroom teaching style interventions and online groups in the included studies. A policy paper on the school health programmes in Asia based on expert workshops discussed the strategy for the implementation of the WHO’s Health Promoting School (HSP) framework. Based on this framework, findings of our scoping review reported the holistic approach through involving adolescents (students), teachers and parents in the health promotion activities through school-based curriculum.31 Five studies implemented educational interventions or assessed stakeholder perceptions—students, teachers, and parents—with the aim of increasing vaccine uptake. Gargano, et al24 in the United States developed and conducted a theoretical framework and initial evaluation of an intervention delivered by teachers over a 120-minute period, and supplemented with parent brochures. Multiple reciprocating relationships between education and health have been constructed by Broman, et al26 in their study to identify opportunities for HPV vaccine education in school-based settings for grade 6 students in British Colombia: • By making school-based programmes studentcentered; • Adopting a collaborative and interdisciplinary approach to vaccine education; and • Actualizing parent education opportunities. These findings from the USA and Canada reflect upon the steps taken in the region at a national level for increasing the awareness among children regarding immunization. These may be closely linked to findings from the states—including Delaware—wherein school-based vaccination requirements are strictly enforced, and all students must provide proof of immunization in line with Centers for Disease Control and Prevention (CDC) guidelines before enrollment in public or private schools. Delaware’s approach, grounded in policy, surveillance, and public health partnerships, offers a relevant example of localized adaptation of global immunization strategies for school-age children. An interesting finding has been reported in evidence generated by Vaivada, et al, wherein it was reported that schools can act as a vital platform for the delivery of the preventive intervention among adolescent population. These interventions were largely focused on infectious diseases, non-communicable diseases, and healthy lifestyles, nutrition, and physical activity.17 A review was conducted by Baltag, et al in 2015 with the aim of providing a global overview of the health services provided through schools in 102 countries. It reported more than 15 intervention or services provided; the top five interventions were vaccinations, sexual and reproductive health education, vision screening, nutrition screening, and nutrition health education.32
Among low-to-middle income countries such as India, schools have served as effective platforms for providing vaccination services during national campaigns—such as the Measles-Rubella catch-up campaigns and the COVID-19 vaccination for children aged 12 and above.33,34 These campaigns have demonstrated the cost-effectiveness and logistical advantage of school-based delivery.35 However, these remain reactive, top-down interventions driven by public health emergencies and typically lack sustained educational components. A lack of a structured and class-wise curriculum in majority of countries has been seen—particularly with respect to immunization—that can systematically introduce or reinforce the importance of immunization across age groups. Even though primary-level students are expected to be sensitized about the importance of vaccination as a preventive measure, the actual implementation of the same to develop vaccine literacy remains limited.
CONCLUSION This scoping review includes the evidence from a few countries that underscore the global relevance of this issue, but also reveals the limited efforts in developing comprehensive, school-based immunization education programs. A majority of evidence was skewed towards developed countries, and was limited to immunity and vaccination related formal education in school-based curriculums. The review also affirms that global efforts to integrate vaccination education into school curricula remains uneven. There is a compelling need for structured, curriculum-based interventions that could contribute significantly to the immunization goals (reducing zerodose children, sustaining measles and rubella elimination, improving coverage of HPV, DPT, Td among school going groups). High income countries and states like Delaware provide a valuable example of state-level commitment to immunization. The state’s comprehensive requirements and collaborative public health partnerships contribute to higher-than-average coverage rates, though recent years have highlighted vulnerability to vaccine hesitancy and disruptions from global events. There appears to be no specific published studies that have directly assessed the impact of a vaccination awareness curriculum specifically implemented in Delaware schools for children to address vaccine hesitancy; adopting curriculumbased interventions tailored to vaccination in Delaware could further strengthen community immunity, mitigate exemption trends, and promote vaccine literacy.
Limitations This scoping review was limited to the English language only, and may have missed non-English language papers. Additionally, the search strategy was run in November 2024; the authors could not run an updated search from the past 6 months. The authors intended to update the search at the completion of one year of searching. Dr. Verma may be contacted at vamit1989@gmail.com. 75
REFERENCES 1. World Health Organization. (2010). Statue commemorates smallpox eradication. https://www.who.int/news/item/17-05-2010-statue-commemorates-smallpoxeradication 2. World Health Organization. (2025). Vaccines and immunization. https://www.who.int/health-topics/vaccines-and-immunization 3. World Health Organization. (2011). Global immunization vision and strategy: Progress report and strategic direction for the decade of vaccines. https://apps.who.int/gb/ebwha/pdf_files/wha64/a64_14-en.pdf 4. Ioannidis, J. P. A., Pezzullo, A. M., Cristiano, A., & Boccia, S. (2025, July 3). Global estimates of lives and life-years saved by COVID-19 vaccination during 20202024. JAMA Health Forum, 6(7), e252223. https://doi.org/10.1001/jamahealthforum.2025.2223 5. World Health Organization. (2025). Essential programme on immunization. https://www.who.int/teams/immunization-vaccines-and-biologicals/essentialprogramme-on-immunization 6. National Health Mission. (2025). Government of India. Immunization. https://nhm.gov.in/index1.php?lang=1&level=2&sublinkid=824&lid=220 7. Kaur, G., Casey, R. M., Patel, J. C., Bloem, P., Walldorf, J. A., & Hyde, T. B. (2023, July 7). Status of new vaccine introduction — Worldwide, 2016–2021. MMWR. Morbidity and Mortality Weekly Report, 72(27), 746–750. https://doi.org/10.15585/mmwr.mm7227a2 8. Bura, V. K., Srivastava, R., Chawla, A. K., Njambe, T. O. E., Khanal, S., Sangal, L., . . . Bahl, S. (2024, September). Essential programme on immunization in WHO South-East Asia: A five-decade journey of saving millions of lives & ending diseases. The Indian Journal of Medical Research, 160(3&4), 267–278. https://doi.org/10.25259/IJMR_1527_2024 9. World Health Organization. (2025). SDG target 3.b. https://www.who.int/data/gho/data/themes/topics/indicator-groups/indicatorgroup-details/GHO/sdg-target-3.b-development-assistance-and-vaccinecoverage 10. World Health Organization. (2020). Immunization agenda 2030: A global strategy to leave no one behind. https://www.who.int/publications/m/item/immunization-agenda-2030-a-globalstrategy-to-leave-no-one-behind 11. World Health Organization. (2024). Immunization coverage. https://www.who.int/news-room/fact-sheets/detail/immunization-coverage 12. Ratna, M., Singh, S. K., Sinha, N. K., Kannure, M., Bhatia, M., Aggarwal, M. K., . . . Shah, V. (2024, August 14). Developing a roadmap to reach and sustain 90% full immunization coverage through a crosssectoral system strengthening strategy in Bihar, India. BMC Health Services Research, 24(1), 933. https://doi.org/10.1186/s12913-024-11380-7 13. World Health Organization. (2024). Immunization 2024 India country profile. https://www.who.int/publications/m/item/immunization-2024-india-countryprofile 14. World Health Organization. (2015). Vaccine hesitancy: A growing challenge for immunization programmes. https://www.who.int/news/item/18-08-2015-vaccine-hesitancy-a-growingchallenge-for-immunization-programmes 15. Shah, G. H., & Nguyen, T. H. (2025, May 16). Vaccine hesitancy through a global lens: Cross-cultural evidence from a special issue. Vaccines, 13(5), 529. https://doi.org/10.3390/vaccines13050529 16. Singh, K., Verma, A., & Lakshminarayan, M. (2022, October). India’s efforts to achieve 1.5 billion COVID-19 vaccinations: A narrative review. Osong Public Health and Research Perspectives, 13(5), 316–327. https://doi.org/10.24171/j.phrp.2022.0104 17. Vaivada, T., Sharma, N., Das, J. K., Salam, R. A., Lassi, Z. S., & Bhutta, Z. A. (2022, May 1). Interventions for health and well-being in school-aged children and adolescents: A way forward. Pediatrics, 149(Suppl 6), e2021053852M. https://doi.org/10.1542/peds.2021-053852M 18. Tuckerman, J., Kaufman, J., & Danchin, M. (2022, May 1). Effective approaches to combat vaccine hesitancy. The Pediatric Infectious Disease Journal, 41(5), e243–e245. https://doi.org/10.1097/INF.0000000000003499 19. World Health Organization. (n.d.). Strengthening community acceptance of vaccines through educational interventions https://www.who.int/europe/activities/strengthening-community-acceptance-ofvaccines-through-educational-interventions
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20. UNESCO. (2023). Ready to learn and thrive: School health and nutrition around the world. UN. https://www.unesco.org/en/articles/ready-learn-and-thrive-school-health-andnutrition-around-world 21. Petersen, P. E., Baez, R. J., & Ogawa, H. (2020, August). Global application of oral disease prevention and health promotion as measured 10 years after the 2007 World Health Assembly statement on oral health. Community Dentistry and Oral Epidemiology, 48(4), 338–348. https://doi.org/10.1111/cdoe.12538 22. Arksey, H., & O’Malley, L. (2005). Scoping studies: Towards a methodological framework. Int J Soc Res Methodol, 8(1), 19–32. https://doi.org/10.1080/1364557032000119616 23. Bocquier, A., Bruel, S., Michel, M., Le Duc-Banaszuk, A. S., Bonnay, S., Branchereau, M., . . . Thilly, N., & the PrevHPV Study Group. (2023, October). Co-development of a school-based and primary care-based multicomponent intervention to improve HPV vaccine coverage amongst French adolescents (the PrevHPV Study). Health Expect, 26(5), 1843–1853. https://doi.org/10.1111/hex.13778 24. Gargano, L. M., Underwood, N. L., Sales, J. M., Seib, K., Morfaw, C., Murray, D., . . . Hughes, J. M. (2015). Influence of sources of information about influenza vaccine on parental attitudes and adolescent vaccine receipt. Human Vaccines & Immunotherapeutics, 11(7), 1641–1647. https://doi.org/10.1080/21645515.2015.1038445 25. Glik, D., Macpherson, F., Todd, W., Stone, K., Ang, A., & Connell Jones, M. (2004, Nov-Dec). Impact of an immunization education program on middle school adolescents. American Journal of Health Behavior, 28(6), 487–497. https://doi.org/10.5993/AJHB.28.6.2 26. Brohman, I., Blank, G., Mitchell, H., Dubé, E., & Bettinger, J. A. (2024, December 31). Opportunities for HPV vaccine education in school-based immunization programs in British Columbia, Canada: A qualitative study. Human Vaccines & Immunotherapeutics, 20(1), 2326779. https://doi.org/10.1080/21645515.2024.2326779 27. Shoker, K., Doornekamp, L., Horjus, B., Wagener, M. N., Aron, G. I., Goeijenbier, M., & van Gorp, E. C. M. (2021, December 23). Empowering Dutch and Surinamese children to prevent viral infections: Implications from an international education module. Health Promotion International, 36(6), 1566–1577. https://doi.org/10.1093/heapro/daaa153 28. Skinner, S. R., Imberger, A., Nolan, T., Lester, R., Glover, S., & Bowes, G. (2000, June). Randomised controlled trial of an educational strategy to increase schoolbased adolescent hepatitis B vaccination. Australian and New Zealand Journal of Public Health, 24(3), 298–304. https://doi.org/10.1111/j.1467-842X.2000.tb01572.x 29. Metreau, E., Young, K. E., & Eapen, S. G. (2024). World Bank country classifications by income level for 2024-2025. World Bank. https://blogs.worldbank.org/en/opendata/world-bank-country-classificationsby-income-level-for-2024-2025 30. Golan, M., & Ahmad, W. A. (2018, December). School-based versus after-school delivery of a universal wellness programme - A randomized controlled multiarm trial. Eating Behaviors, 31, 41–47. https://doi.org/10.1016/j.eatbeh.2018.08.003 31. Ogasawara, R., Yamanaka, H., Kobayashi, J., Tomokawa, S., Sugita, E., Hirano, T., . . . Yamamoto, B. A. (2022, January). Status of school health programs in Asia: National policy and implementation. Pediatr Int, 64(1), e15146. https://doi.org/10.1111/ped.15146 32. Baltag, V., Pachyna, A., & Hall, J. (2015). Global overview of school health services: Data from 102 Countries. Health Behavior and Policy Review, 2(4), 268–283. https://doi.org/10.14485/HBPR.2.4.4 33. Peebles, A., MacDonald, S. E., & Basta, N. E. (2022, November). School-based COVID-19 vaccination programmes: An equitable strategy to reduce the impact of COVID-19 on children and their families. Lancet Regional Health. Americas, 15, 100365. https://doi.org/10.1016/j.lana.2022.100365 34. Bola, O., Oteri, A. J., Bawa, S., Nkwogu, L., Wagai, J., Oladele, A., . . . Braka, F. (2022). The role of school engagement in increasing vaccination during measles mass vaccination campaign in Nigeria, 2018: The Lagos State Experience. J Biomed Res Environ Sci, 3(3), 268–276. https://doi.org/10.37871/jbres1432 35. Fontanesi, J., & Jue-Leong, S. (2012, Sep-Oct). Logistical and fiscal sustainability of a school-based, pharmacist-administered influenza vaccination program. J Am Pharm Assoc, 52(5), e74–e79. https://doi.org/10.1331/JAPhA.2012.10113
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Hepatitis B Birth Dose Stephen C. Eppes, M.D. President, Delaware Academy of Medicine and Public Health Katherine Smith, M.D., M.P.H. Executive Director, Delaware Academy of Medicine and Public Health
Last week, the Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP) voted to downgrade its longstanding recommendation to vaccinate all newborns against hepatitis B at birth. The newly formed ACIP has, under the leadership of HHS Secretary RFK, Jr., become decidedly anti-vaccine. ACIP now emphasizes routine hepatitis B screening of pregnant women so that children born to uninfected mothers may have their birth dose deferred. Unfortunately, some women become infected with HBV after their first trimester screening, and some are never screened at all, due to late (or no) prenatal care or to medical error. The Delaware Academy of Medicine and Public Health strongly opposes these decisions by ACIP, which were not based on any new data or evidence.
The American Academy of Pediatrics continues to recommend the full series of hepatitis B vaccines, including the birth dose, for all infants, based on the science and the proven success of this strategy. Other professional societies are on board with this recommendation, including the American College of Obstetricians and Gynecologists, the American College of Physicians, the American Association of Family Physicians, and the Infectious Diseases Society of America.2
Prior to 1991, about 30,000 children under 10 years old in the U.S. were chronically infected with hepatitis B virus. About half of these children got the virus from their infected mother, but the other half were infected during early childhood due to relatively casual contact from others in their environment. Over time, chronic infection leads to liver disease, cirrhosis, and risk for hepatocellular carcinoma. In 1991, the recommendation for universal hepatitis B immunization of Hepatitis infants, including a birth dose, Universal Universal Hepatitis B Vaccination B Vaccination at Birth at Birth was implemented. This has been a resounding public health December December 2, 2025 2, 2025 success story with a 99% reduction in childhood HBV infection in the U.S. (figure 1).
2. Infectious Disease Society of America. (2025, Dec). IDSA media briefing: Six medical groups to offer insight on federal vaccine recommendations. Video: https://www.idsociety.org/multimedia/idsa-media-briefingsix-medicalgroups-to-offer-insight-on-federal-vaccine-recommendations/
The Academy encourages clinicians to continue to advocate for the birth dose of hepatitis B vaccine for their patients.
REFERENCES 1. Center for Infectious Disease Research and Policy. (2025). Universal hepatitis B vaccination at birth: Safety, effectiveness, and public health impact. https://www.cidrap.umn.edu/sites/default/files/searchable-download/ Universal%20Hepatitis%20B%20Vaccination%20at%20Birth%202Dec2025.pdf
Figures Figures andand Tables Tables
Figure 1. Timeline of HBV Infection in the USA (Figure by CIDRAP,1 Annotated by Your Local Epidemiologist)
When we switched from High-Risk vaccination to universal, HEP B cases declined.
78 Delaware Journal of Public Health - December 2025
Doi: 10.32481/djph.2025.12.10
Figure Figure 1: Reported 1: Reported number number of acute of acute hepatitis hepatitis B cases B cases in the in United the United States States by year, by year,
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Progress Made, But the Work Isn’t Done: Delaware’s Path on Maternal and Infant Health Melissa C. Minor-Brown, M.A. Speaker of the House, Delaware House of Representatives Marie Pinkney, L.C.S.W. Delaware State Senator, Senate District 13
In recent years, Delaware has made real gains in maternal and infant health. After years of sobering statistics, we cut our infant mortality rate by nearly half and achieved parity with the national rate for the first time.1 This improvement is meaningful, and beyond statistics, it represents families who did not have to endure the loss of a child, and communities where healthier starts in life are becoming more attainable. But even with that improvement, there is still a reality on the ground that we can’t ignore: not all families are experiencing this progress equally. Racial disparities -- especially for Black mothers and infants -- continue to persist. In 2019, Black women made up 28% of live births in Delaware, but they represented 78% of pregnancy-related deaths in 2017 to 2021.2 This is why the passage of the Delaware Momnibus package in 2022 was so significant.3 It marked one of the most comprehensive efforts our state has undertaken to support maternal health, confront disparities, and strengthen care at every stage of pregnancy and postpartum. The package included HB 344, which created bias and competency training for healthcare workers and requires the Delaware Perinatal Quality Collaborative to create training guidelines for health professionals. Two additional bills, HB 343 and HB 234, aim to increase stability and access for mothers and infants who might otherwise face gaps in care. HB 343 extends Medicaid coverage to include doula services, offering mothers additional support, advocacy, and culturally informed care. HB 234 ensures that Medicaid coverage continues throughout the first full year postpartum, a crucial period when many health complications arise and continuous care is essential. Besides being beneficial for new mothers, this extended postpartum coverage allows providers to focus on delivering quality preventive care rather than navigating interruptions in insurance or delayed access to services. The Momnibus also ensures that incarcerated women receive dignified, appropriate maternal care. HB 342 prohibits the use of restraints on women in their second and third trimester and during the 13-week postpartum period, a necessary protection for both safety and human dignity. HB 345 further expands support by providing access to doula services for pregnant and postpartum women in custody, recognizing that pregnancy does not pause while a person is incarcerated and that their health needs to be protected and prioritized. Finally, the package strengthened the state’s oversight and accountability. One bill updates the responsibilities of what is now the Child and Maternal Death Review Commission, directing it to examine maternal and infant mortality more deeply in an effort to 80 Delaware Journal of Public Health - December 2025
connect policy and frontline experience, helping to align systems, standards, and resources to better support providers.4 The Commission is tasked with presenting recommendations not only on deaths, but on complications related to pregnancy and childbirth and on the racial disparities that continue to drive unequal outcomes. Tracking this data is essential, but understanding the stories behind the numbers - and acting on them - is what leads to real change. But we know that the reasons behind the statistics are not solely clinical. They also include the social determinants of health, including transportation, housing stability, workplace protections, access to nutritious food, and the ability to receive care without bias or barriers. Training and policy reforms matter a lot, but they cannot stand alone. A truly holistic approach must address the full lifecycle of maternal health, supporting women before, during, and long after birth. The Delaware Momnibus marked a pivotal moment in our state’s commitment to improving maternal health and reducing infant mortality. In both chambers, we have continued to build upon that progress to better support Delaware mothers, their children, and their families. One notable example is Senate Bill 340, which we were both excited to support as co-sponsors during its successful passage in 2023. That legislation is vitally important because it recognizes that mental health challenges during pregnancy and after birth are factors that many mothers deal with. This legislation is critically important because it acknowledges the reality that mental health challenges during pregnancy and the postpartum period affect many families. Conditions such as anxiety, panic disorders, obsessive-compulsive symptoms, and trauma can have profound and lasting impacts — not only on mothers, but also on children, fathers, and overall family stability. Senate Bill 340 expanded the previously-limited definition of “maternal depression” to reflect the full spectrum of perinatal mental health conditions many mothers face. It also broadened access to care by recognizing that these challenges can affect any caregiver, not just the birthing parent. Together, these efforts exemplify the General Assembly’s inclusive, forward-looking approach to maternal and child health — prioritizing early identification, reducing stigma, expanding access to treatment, and strengthening support systems to improve outcomes for infants, parents, and families across Delaware. We have also recognized the disparities within this area, specifically for people of color. That is why, for multiple years running, the General Assembly has recognized Black Maternal Health Week from every April 11 through April 17 to bring awareness to this extremely important topic. Doi: 10.32481/djph.2025.12.11
This work reflects the values nurses bring to maternal and perinatal care every day: continuity of care that does not end at delivery, listening to patients and families, and designing systems that work for people rather than forcing individuals to navigate these important issues on their own. These legislative initiatives have not only improved outcomes for mothers and infants, but have also continued our commitment to support a nursing workforce that is best equipped and empowered to deliver compassionate care throughout the full spectrum of pregnancy, birth, and postpartum. The progress we’ve made matters, but it’s only the beginning. If we’re serious about closing the gaps and truly addressing the root causes of the disparities we’re seeing, we have to look beyond the statistics and listen to the lived experiences of Black mothers in Delaware – many of whom have stories about being ignored, dismissed, or denied adequate care. We also have to recognize that although we have laid important groundwork through the Momnibus and other recent reforms, the momentum is not self-sustaining. Especially when we’re up against the longstanding underrepresentation of women in medical research, the minimization of their symptoms, and the historic sidelining of their health needs in both clinical and policy environments. These systemic issues have disproportionately impacted women of color, whose experiences reflect disparities that have spanned generations.
But we don’t have to accept these disparities as inevitable or these experiences as normal. If Delaware lawmakers and medical professionals keep their focus, continue to elevate women’s health as a priority, and listen closely to the families who have been most affected, then a healthier, more equitable future for every mother and child remains firmly within reach. To sustain and build upon Delaware’s progress, we must continue to prioritize strong partnerships and targeted investments in the maternal and child health workforce to ensure that today’s gains become tomorrow’s standard.
REFERENCES 1. Thrives, D. E. (n.d.). Strategic initiatives. Retrieved from https://dethrives.com/dhmic/strategic-initiatives 2. Perez-Gonzalez, J. (2024, Apr). Delaware faces persistent health disparities, particularly for Black maternal health. WHYY. Retrieved from https://whyy.org/articles/black-maternal-health-week-delaware/ 3. Kirkpatrick, Q. (2022, July). Six maternal and infant-health related bills are signed into Delaware law. Delaware Public Media. Retrieved from https://www. delawarepublic.org/delaware-headlines/2022-07-25/six-maternal-and-infanthealth-related-bills-are-signed-into-delaware-law 4. Delaware Courts. (n.d.). Maternal and child death review commission. Retrieved from https://courts.delaware.gov/childdeath/
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Children’s Health: 2025 and Beyond Stephen C. Eppes, M.D. President, Delaware Academy of Medicine and Public Health
In May 2025, I read the “Make Our Children Healthy Again” report,1 part of the MAHA movement led by DHHS Secretary Robert F. Kennedy, Jr. While it discussed some significant issues related to children’s health, it also neglected to address some other truly important issues. For example, although red dye additives to food (opposed by the report) may have some minor health issues, I suspect most parents, health care providers, and public health experts would recognize that firearm injuries are the number one killer of children in the United States, not Skittles. Guns are not mentioned in the MAHA report. Neither are motor vehicle crashes nor drug overdoses, other common causes of childhood fatalities. There was an excellent editorial2 published in the New England Journal of Medicine which I would urge our readers to look at. The authors focus in large part on the social determinants of child health. Lacking in the MAHA report is the fact that the United States has one of the highest rates of child poverty among industrialized nations, an important contributing factor to high rates of asthma, obesity and behavioral health issues. While the MAHA report does address two important threats to child health, exposure to environmental chemicals and alarming declines in physical activity, it falls short of recommending regulatory changes. The MAHA commission charges schools with increasing physical activity, but does not address how early childhood and community-based physical activity programs, or any social media strategies, can promote healthy lifestyle choices which would improve health and reduce stress among young people. The MAHA report devotes eight pages to the “overmedicalization of our kids,” a potentially important issue. But throughout this section of the document, risks of medical and surgical interventions are emphasized, with little mention of the important benefits. It decries the “child chemical and surgical mutilation” for management of transgender youth, which on Dec. 18, 2025 RFK Jr. described as malpractice. And it should come as no surprise that the report is decidedly anti-vaccine, totally ignoring the important advances in health, both adult and child, directly attributable to vaccines. Following the publication of this report in May, RFK Jr. has taken multiple steps to dismantle immunization infrastructure, which will negatively impact the health of children. The Immunization Coalition of Delaware, a program of the Academy, has opposed recent actions by the Advisory Committee on Immunization Practices (ACIP) which was totally revamped by RFK Jr.
The American Academy of Pediatrics (AAP)3 currently has a number of advocacy priorities relating to children’s health: • Speaking out in support of childhood immunizations; • Prioritizing child health legislation in Congress, including ⚬ Gun violence prevention research, ⚬ Accelerating pediatric cancer treatments, ⚬ Raising awareness about HPV and HPV-associated cancers; • Opposing immigration policies harmful to children and families; and • Advocating for child health as the 2025 budget reconciliation bill is implemented. The Delaware Academy of Medicine and Public Health stands in support of these priorities and the work of the Delaware chapter of the AAP, ably led by its president, Dr. Jonathan Miller, who is a board member of the Academy. Locally and nationally, those working to advance children’s health should be implementing policies, programs and research supported by the strong evidence base that clinicians and investigators have built painstakingly for many years.2,4 Dr. Eppes may be contacted at seppes@christianacare.org.
REFERENCES: 1. Make America Healthy Again Commission. (2025, May). Make Our Children Healthy Again: An Assessment (Report). The White House. https://www.whitehouse.gov/wp-content/uploads/2025/05/WH-The-MAHAReport-Assessment.pdf 2. Perrin, J. M., & Cheng, T. L. (2025, November 13). Truly prioritizing child health – the missed opportunities of the MAHA Commission. The New England Journal of Medicine, 393(19), 1869–1872. https://doi.org/10.1056/NEJMp2509513 3. American Academy of Pediatrics. (2025). Advocacy snapshot: Ways AAP is speaking up. https://www.aap.org/en/advocacy/ 4. National Academies of Sciences, Engineering, and Medicines. (2024). Launching lifelong health by improving healthcare for children, youth and families. Washington, DC: National Academies Press.
I believe, and I think I speak for the Academy here, that Perrin and Cheng2 are correct that any changes to policies involving children’s health “should build on the extraordinary research achievements that have improved child health over the past 50 years [including] increased life expectancy for children with cancer, sickle cell anemia and cystic fibrosis; reductions in sudden infant deaths; surfactant saving premature babies; prevention of maternal-fetal HIV transmission; and injury prevention with car seats and seatbelts.” 82 Delaware Journal of Public Health - December 2025
Doi: 10.32481/djph.2025.12.12
Index of Advertisers The Nation's Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 American Public Health Association Qualitative PFAS Health Study. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Indiana University Children's Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Delaware Child Psychiatry Access Program 2025: Head Start Delaware . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 First Five Years Fund Naloxone Access Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 DSAMH Submission Guidelines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 Delaware Journal of Public Health
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RESOURCES Maternal and Child Health Resources Birth to Three Delaware https://www.b23de.org Delaware’s Birth to Three Early Intervention Program (B23) supports families with infants and toddlers who have, or are at risk of, developmental delays or disabilities. Together, we help your child reach their full potential through assessments, personalized plans, and expert guidance.
Black Mothers in Power https://www.blackmothersinpower.org/ Black Mothers in Power seeks to dismantle systems of Maternal and Child Health Resources to eradicate the racial health disparities that harm Black birthing people and Black babies throughout Delaware - while building new systems of care, healing, and power designed by and for us.
Children & Families First https://www.cffde.org/healthybabies Smart Start offers special services to help women have healthy babies and raise healthy children. Services include home visits to teach new mothers and mothers-to-be about pregnancy, labor and delivery, and caring for children.
Do Care Doula Foundation https://www.dedoulas.com Do Care Doula Foundation Inc is dedicated to holistically supporting families during pregnancy, birth, and well beyond. We are committed to reducing maternal health disparities by addressing the physical, emotional, and educational needs that often impact outcomes for underserved and marginalized communities. Through compassionate care, advocacy, and access to essential resources, we nurture the overall growth and well-being of every family we serve.
Healthy Women, Healthy Babies https://www.dethrives.com/programs/healthy-women-healthy-babies#find-a-provider The Healthy Women, Healthy Babies (HWHB) Program is a program that offers extra services to women who are pregnant or planning a pregnancy, or who just want to live a healthier life. These include personal health and wellness, nutrition, family planning, mental health, and prenatal care. Services are facilitated through health care organizations and clinic sites that contract with the Division of Public Health (DPH) to conduct program outreach, enrollment, and deliver service bundles.
Jewish Family Services of Delaware https://www.jfsdelaware.org/maternal-mental-health/ The Sonia Schorr Sloan Maternal Mental Health Program is a community-based, outpatient program which provides effective, evidence-based psychotherapy and maternal behavioral health care for people who experience pregnancy loss and/or perinatal mood and anxiety disorders (PMADs). Such support and education will help ensure you gain and strengthen the coping skills to move forward, successfully recover, and care for yourself and your family.
Maternal and Child Health Bureau, State of Delaware https://www.dhss.delaware.gov/dph/chca/dphmchhome/
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RESOURCES New Directions Early Head Start https://www.ndehs.udel.edu/ New Directions Early Head Start (NDEHS) provides pregnant people, infants, toddlers and their families with quality care and family services. We support families by providing the best services for them and their very young children with the goal to promote children’s success and families’ self-sufficiency through community collaboration and partnerships. This includes both home-based and center-based services for families.
Parents as Teachers https://www.education.delaware.gov/families/birth-age-5/early_resources/parents_as_teachers/ Parents as Teachers (PAT) is a program which provides visits to families in their homes to support pregnant mothers and children from birth through kindergarten.
Planned Parenthood of Delaware https://www.plannedparenthood.org/planned-parenthood-delaware/our-services Planned Parenthood of Delaware provides high-quality sexual and reproductive health care throughout Delaware.
Sussex Pregnancy Care Center https://www.sussexpregnancy.com Sussex Pregnancy Care Center has been providing free, confidential, compassionate care and support to individuals making decisions about an unplanned pregnancy since 1985. Our staff and trained volunteers are here, ready to listen. We are a non-profit organization funded by the generosity of individuals, businesses, churches and community organizations.
Delaware Healthcare Institution Maternity Services Bayhealth Maternity & Obstetrics https://www.bayhealth.org/services/womens-childrens-health/maternity-obstetrics ChristianaCare Pregnancy & Childbirth https://www.christianacare.org/us/en/care/womens-healthcare/pregnancy-and-childbirth La Red Health Center Women’s Health & Prenatal Services https://www.laredhealthcenter.org/care/womens-health Nemours Children’s Health https://www.nemours.org/ Westside Health Women’s Health https://www.westsidehealth.org/services/womens-health/
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Delaware Journal of
Public Health
Submission Guidelines
updated November, 2025
About the Journal Established in 2015, the Delaware Journal of Public Health is a peer-reviewed electronic publication created by the Delaware Academy of Medicine and Public Health. The publication acts as a repository of news for the medical, dental, and public health communities, and is comprised of upcoming event announcements, past conference synopses, local resources, and peer-reviewed content ranging from manuscripts and research papers to opinion editorials and personal interest pieces, all relating to the public health sector in Delaware. Each issue is largely devoted to an overarching theme or current issue in public health. DJPH content is informed by the interest of our readers and contributors. If you have an event coming up, would like to contribute to an Op-Ed, would like to share a job posting, or have a topic in public health you would like to see covered in an upcoming issue, please let us know. If you are interested in submitting an article to the Delaware Journal of Public Health, or have any additional inquiries regarding the publication, please contact us at managingeditor@djph.org .
Information for Authors The DJPH accepts a wide variety of submission formats, including research articles, systematic reviews, letters to the editor, commentaries/ narratives, analytic essays, history essays, public health practice vignettes, and interviews. The DJPH also accepts images and advertisements pertaining to relevant, upcoming public health events, and presentation reviews. Additional types of submission not previously mentioned may be eligible; please contact us for more information. The initial submission should be clean and complete, without edits or markups, and contain both the title and the author(s) full name(s). Submissions should be 1.5 or double spaced with a font size of 12. Articles may be submitted through our online portal, at https://djph.org/submissions/submit-an-article . Graphics, images, info-graphics, tables, and charts are welcome and encouraged to be included in articles. Please ensure that all pieces are in their final format, and all edits and track changes have been implemented prior to submission. To view additional submission requirements, please refer to the website (https://djph.org/submissions/submit-an-article). 86 Delaware Journal of Public Health - December 2025
Trial registration information is required for all clinical trials and must be included in the final article.
Abstracts Authors must submit a structured or unstructured abstract along with their article. Abstracts should have a minimum of 200 words, including headings. Please see the submission guidelines for more information.
Submission Length While there is no prescribed word length, full articles will generally be in the 2,500 to 4,000-word range, and editorials or narratives in the 1,500 to 2,500-word range. If there are any questions about the length of the submission, please contact us.
Copyright The DJPH and its content is copyrighted by the Delaware Academy of Medicine and Public Health. The contents are listed under Creative Commons License – CC BY-NC-ND.
Images are NOT covered under the Creative Commons license and are the property of the original photographer or company who supplied the image. Opinions expressed by authors of articles summarized, quoted, or published in full within the DJPH represent only the opinions of those authors and do not necessarily reflect the official policy of the Academy, the DJPH, or the institution with which the authors are affiliated.
Nondiscriminatory Language Use of nondiscriminatory language is required in all DJPH submissions. The DJPH reserves the right to reject any submission found to be using sexist, racist, or heterosexist language, as well as unethical or defamatory statements.
Conflicts of Interest Any conflicts of interest, including political, financial, personal, or academic conflicts, must be declared prior to the submission of the article, or in conjunction with a submission. Conflicts of interest are any competing interests that may leave readers feeling misled or deceived, and/or alter their perception of subject matter. Declared conflicts of interest will be published alongside articles in the final publication.
87
Delaware Academy of Medicine and Public Health
P.O. Box 89 Historic New Castle, DE 19720
www.delamed.org Follow Us:
The Delaware Academy of Medicine and Public Health is a private, nonprofit organization. The Academy was founded in 1930 as the Delaware Academy of Medicine. The Delaware Public Health Association was officially reborn at the 141st Annual Meeting of the American Public Health Association (APHA) held in Boston, MA. At this meeting, on November 5, 2013, the DPHA was officially transferred to the Delaware Academy of Medicine by action of the APHA Governing Council. The mission of the Delaware Academy of Medicine and Public Health is to enhance the well being of our community through education, the promotion of public health, research, and targeted investments in human capital and development.
ISSN 2639-6378