BACKGROUND AND OBJECTIVES: Youth with chronic physical conditions (CPCs) may be at greater risk for developing chronic mental health conditions (MHCs), and limitations in the ability to engage in developmentally appropriate activities may contribute to the risk of MHCs among youth with CPCs. We compared the risk of incident MHCs in youth with and without CPCs and explored whether activity limitations contribute to any such association. METHODS: The 2003-2014 Medical Expenditure Panel Survey provided a nationally representative cohort of 48 572 US youth aged 6 to 25 years. We calculated the 2-year cumulative incidence of MHCs overall and by baseline CPC status. Cox proportional hazard models were used to estimate the association between CPCs and incident MHCs, adjusting for sociodemographic characteristics. Stepwise models and the Sobel test evaluated activity limitations as a mediator of this relationship. RESULTS: The 2-year cumulative incidence of MHCs was 7.8% overall, 11.5% in youth with CPCs (14.7% of sample), and 7.1% in those without. The adjusted risk of incident MHCs was 51% greater (adjusted hazard ratio 1.51; 95% confidence interval 1.30-1.74) in youth with CPCs compared with those without. Activity limitations mediated 13.5% of this relationship ( < .001). CONCLUSIONS: This nationally representative cohort study supports the hypotheses that youth with CPCs have increased risk for MHCs and that activity limitations may play a role in MHC development. Youth with CPCs may benefit from services to bolster their ability to participate in developmentally important activities and to detect and treat new onset MHCs.

Background
Children with Juvenile Idiopathic Arthritis (JIA) often have poor health-related quality of life (HRQOL) despite advances in treatment. Patient-centered research may shed light on how patient experiences of treatment and disease contribute to HRQOL, pinpointing directions for improving care and enhancing outcomes.

Methods
Parent proxies of youth enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry shared patient-reported outcomes about their child’s HRQOL and experiences of disease and treatment burden (pain interference, morning stiffness, history of medication side effects and methotrexate intolerance). Contributions of these measures to HRQOL were estimated using generalized estimating equations accounting for site and patient demographics.

Results
Patients (N = 180) were 81.1% white non-Hispanic and 76.7% female. Mean age was 11.8 (SD = 3.6) years, mean disease duration was 7.7 years (SD = 3.5). Mean Total Pediatric Quality of Life was 76.7 (SD = 18.2). Mean pain interference score was 50.1 (SD = 11.1). Nearly one-in-five (17.8%) youth experienced >15 min of morning stiffness on a typical day, more than one quarter (26.7%) reported ≥1 serious medication side effect and among 90 methotrexate users, 42.2% met criteria for methotrexate intolerance. Measures of disease and treatment burden were independently negatively associated with HRQOL (all p-values <0.01). Negative associations among measures of treatment burden and HRQOL were attenuated after controlling for disease burden and clinical characteristics but remained significant.

Conclusions
For youth with JIA, HRQOL is multidimensional, reflecting disease as well as treatment factors. Adverse treatment experiences undermine HRQOL even after accounting for disease symptoms and disease activity and should be assessed routinely to improve wellbeing.
 

PURPOSE: While education-based disparities in health are common, the extent to which chronic conditions contribute to education gaps and to consequent health disparities is not fully understood. As such, we sought to investigate educational aspirations, expectations, and attainment among youth with and without chronic conditions and to determine if these relationships mediated subsequent disparities in health and well-being. METHODS: Longitudinal data on 3,518 youths are from the 1997-2013 Panel Study of Income Dynamics, a population-based survey. Multivariate regression was used to assess disparities in educational aspirations, expectations, and attainment by chronic conditions and the subsequent effects on health and well-being, adjusting for important potential confounders. RESULTS: Youth with chronic medical conditions (YCMCs) did not report significantly lower educational aspirations than their healthy peers; however, YCMC reported lower expectations for their educational attainment and fewer YCMC had earned their desired degree by the end of follow-up (e.g., ≥bachelor's degree: 19.9% for YCMC vs. 26.0% for peers, p < .05). YCMC reported significantly worse general health, lower life satisfaction, and lower psychological well-being in young adulthood than did their healthy peers. These disparities persisted after adjustment for confounders; the association between chronic disease and health was partially, but significantly, mediated by actual educational attainment. CONCLUSIONS: Findings suggest an important risk mechanism through which YCMC may acquire socioeconomic disadvantage as they develop and progress through educational settings. Disproportionate lags in education, from expectation to attainment, may in turn increase YCMC's susceptibility to poor health and well-being in the future.

The purpose of this study was to determine the relationships among preconception stressful life events (PSLEs), women's alcohol and tobacco use before and during pregnancy, and infant birthweight. Data were from the Early Childhood Longitudinal Study-Birth Cohort (n = 9,350). Data were collected in 2001. Exposure to PSLEs was defined by indications of death of a parent, spouse, or previous live born child; divorce or marital separation; or fertility problems prior to conception. Survey data determined alcohol and tobacco usage during the 3 months prior to and in the final 3 months of pregnancy. We used staged multivariable logistic regression to estimate the effects of women's substance use and PSLEs on the risk of having a very low (<1,500 g, VLBW) or low (1,500-2,499 g, LBW) birthweight infant, adjusting for confounders. Women who experienced any PSLE were more likely to give birth to VLBW infants (adjusted odds ratio [AOR] = 1.35; 95 % confidence interval [CI] = 1.10-1.66) than women who did not experience any PSLE. Compared to women who never smoked, women who smoked prior to conception (AOR = 1.31; 95 % CI = 1.04-1.66) or during their last trimester (AOR = 1.98; 95 % CI = 1.56-2.52) were more likely to give birth to LBW infants. PSLEs and women's tobacco use before and during pregnancy are independent risk factors for having a lower birthweight baby. Interventions to improve birth outcomes may need to address women's health and health behaviors in the preconception period.

Mental health problems disproportionately affect women, particularly during childbearing years. We sought to estimate the prevalence of antepartum mental health problems and determine potential risk factors in a representative USA population. We examined data on 3,051 pregnant women from 11 panels of the 1996-2006 Medical Expenditure Panel Survey. Poor antepartum mental health was defined by self report of mental health conditions or symptoms or a mental health rating of "fair" or "poor." Multivariate regression analyses modeled the odds of poor antepartum mental health; 7.8% of women reported poor antepartum mental health. A history of mental health problems increased the odds of poor antepartum mental health by a factor of 8.45 (95% CI, 6.01-11.88). Multivariate analyses were stratified by history of mental health problems. Significant factors among both groups included never being married and self-reported fair/poor health status. This study identifies key risk factors associated with antepartum mental health problems in a nationally representative sample of pregnant women. Women with low social support, in poor health, or with a history of poor mental health are at an increased risk of having antepartum mental health problems. Understanding these risk factors is critical to improve the long-term health of women and their children.

PURPOSE: To determine if caring for a child with cancer or a brain tumor affects parental health and mental health and if and to what extent stress mediates the relationship between case status and parental quality of life. METHODS: In person interviewer-assisted surveys were administered to 74 case dyads (children diagnosed with cancer or a brain tumor and their parents) and 129 control dyads (children without health problems and their parents from a community sample) to assess health-related quality of life and perceived levels of stress. RESULTS: Parents of children with cancer or a brain tumor had significantly worse health-related quality of life, including worse overall mental health. Overall physical health was no different between cases and controls. Staged multivariate analysis revealed that worse health-related quality of life is completely mediated by perceived stress in these parents. CONCLUSIONS: The experience of caring for a child with cancer is not in itself related to poor quality of life, but is related to an increased level of stress that may adversely impact parental mental health and quality of life.

PURPOSE: Mental health problems disproportionately affect women, particularly during the childbearing years. However, there is a paucity of research on the determinants of postpartum mental health problems using representative US populations. Taking a life course perspective, we determined the potential risk factors for postpartum mental health problems, with a particular focus on the role of mental health before and during pregnancy. METHODS: We examined data on 1,863 mothers from 11 panels of the 1996-2006 Medical Expenditure Panel Survey. Poor postpartum mental health was defined using self-reports of mental health conditions, symptoms of mental health conditions, or global mental health ratings of "fair" or "poor." RESULTS: Of the women included, 9.5% reported experiencing postpartum mental health problems, with over half of these women reporting a history of poor mental health. Poor prepregnancy mental health and poor antepartum mental health both independently increased the odds of having postpartum mental health problems. Staged multivariate analyses revealed that poor antepartum mental health attenuated the relationship between prepregnancy and postpartum mental health problems. Additionally, significant disparities exist in women's report of postpartum mental health status. CONCLUSION: Although poor antepartum mental health is the strongest predictor of postpartum mental health problems, prepregnancy mental health is also important. Accordingly, health care providers should identify, treat, and follow women with a history of poor mental health because they are particularly susceptible to postpartum mental health problems. This will ensure that women and their children are in the best possible health and mental health during the postpartum period and beyond.

OBJECTIVES: We sought to determine if and to what extent a woman's exposure to stressful life events prior to conception (PSLEs) were associated with subsequent infant birth weight by using a nationally representative sample of US women. METHODS: We examined 9350 mothers and infants participating in the first wave of the Early Childhood Longitudinal Study, Birth Cohort in 2001. Weighted regressions estimated the effect of exposure on very low and low birth weight, adjusting for maternal sociodemographic and health factors and stress during pregnancy. RESULTS: Twenty percent of women experienced any PSLE. In adjusted analyses, exposed women were 38% more likely to have a very low birth weight infant than nonexposed women. Furthermore, the accumulation of PSLEs was associated with reduced infant birth weight. CONCLUSIONS: This was the first nationally representative study to our knowledge to investigate the impact of PSLEs on very low and low birth weight in the United States. Interventions aimed to improve birth outcomes will need to shift the clinical practice paradigm upstream to the preconception period to reduce women's exposure to stress over the life course and improve the long-term health of children.

PURPOSE: Research suggests a relationship between caring for a child with cancer and psychological distress in caregivers. Less evident is the role which financial difficulties might play in this relationship. We sought to determine if caring for a child with cancer was related to clinically relevant depressive symptoms among parents, whether or not financial difficulties mediated this relationship, and if financial difficulties were independently associated with symptoms of depression among parents of children with cancer. METHODS: Data are from 215 parents of children diagnosed with cancer or brain tumors (n = 75) and a comparison group of parents of healthy children (n = 140). Multiple logistic regression analyses were used to assess the factors associated with reporting clinically relevant depressive symptoms. RESULTS: Caring for a child with cancer was associated with increased odds of clinically relevant depressive symptoms in parents (OR = 4.93; 95 % CI 1.97-12.30), controlling for covariates. The mediating effect of financial burden on this relationship was not statistically significant. However, among parents of children with cancer, negative financial life events increased the likelihood of reporting symptoms of depression (OR = 4.89; 95 % CI 1.26-18.96). CONCLUSIONS: Caring for a child with cancer was associated with depressive symptoms for parents. Financial difficulties were the strongest correlate of these symptoms among parents of children with cancer. Our results suggest that it may not only be the burden of caring for the child with cancer but also the associated financial difficulties that contribute to a higher likelihood of depressive symptoms in parents.

Stress during pregnancy is a salient risk factor for adverse obstetric outcomes. Personal capital during pregnancy, defined as internal and social resources that help women cope with or decrease their exposure to stress, may reduce the risk of poor obstetric outcomes. Using data from the 2007 Los Angeles Mommy and Baby study (N = 3,353), we examined the relationships between the balance of stress and personal capital during pregnancy, or the stress-to-capital ratio (SCR), and adverse obstetric outcomes (i.e., pregnancy complications, preterm birth (PTB), low birth weight (LBW), and small for gestational age (SGA)). Women with a higher SCR (i.e., greater stress relative to personal capital during pregnancy) were significantly more likely to experience at least one pregnancy complication, PTB, and lower gestational age, but not LBW or SGA. Accounting for pregnancy complications completely mediated the association between the SCR and PTB. Our findings indicate that experiencing greater stress relative to personal capital during pregnancy is associated with an increased risk for pregnancy complications, PTB, and lower gestational age and that pregnancy complications may be a mechanism by which the SCR is related to adverse obstetric outcomes.

The objectives of this study were to determine if racial and ethnic differences in personal capital during pregnancy exist and to estimate the extent to which any identified racial and ethnic differences in personal capital are related to differences in maternal sociodemographic and acculturation characteristics. Data are from the 2007 Los Angeles Mommy and Baby study (n = 3,716). Personal capital comprised internal resources (self-esteem and mastery) and social resources (partner, social network, and neighborhood support) during pregnancy. The relationships between race/ethnicity and personal capital were assessed using multivariable generalized linear models, examining the impact of sociodemographic and acculturation factors on these relationships. Significant racial and ethnic disparities in personal capital during pregnancy exist. However, socioeconomic status (i.e., income and education) and marital status completely explained Black-White disparities and Hispanic-White disparities in personal capital, whereas acculturation factors, especially nativity and language spoken at home, partially mediated the disparities in personal capital between Asian/Pacific Islander women and White women. Findings suggest that the risks associated with low socioeconomic status, single motherhood, and low acculturation, rather than race or ethnicity, contribute to low personal capital for many pregnant women. As personal capital during pregnancy may influence subsequent maternal and child health outcomes, the development of interventions should consider addressing sociodemographic and acculturation factors in order to reduce racial and ethnic disparities in personal capital and ultimately in poor maternal and child health outcomes.

OBJECTIVE: First, we sought to determine if parents of children with cancer or a brain tumor had greater stress compared to parents of healthy children and to evaluate the correlates of stress among parents of children with cancer or brain tumors. Second, we sought to examine the relationship between perceived stress and symptoms of stress and how that relationship may differ for parents of children with cancer. METHODS: In-person, interviewer-assisted surveys were administered to 73 case dyads (children with cancer or a brain tumor and their parents) and 133 comparison dyads (children without health problems and their parents from a community sample). Descriptive analyses and multivariable logistic regressions were performed for case-comparison and case-only analyses to distinguish correlates of parental stress. RESULTS: Parents of children with cancer exhibited higher levels of physiological symptoms of stress than parents of healthy children. Poor sleep quality and greater social stress (negative social interactions) were significant correlates of increased levels of stress in parents of children with cancer (odds ratio 4.23, 95% confidence interval 1.15-15.60; and odds ratio 1.07, 95% confidence interval 1.00-1.14, respectively). A subset of parents reported symptoms of stress but not perceived stress, and this discordance was more pronounced among cancer caregivers. CONCLUSIONS: Implementation of screening tools that include symptoms of stress may help clinicians to comprehensively identify parents of children with cancer who are in need of additional services. Targeted stress-reduction interventions that address sleep quality and negative social interactions may mitigate the deleterious effects of caregiving, improving the psychosocial well-being of both parents and children with cancer.

OBJECTIVE: This study sought to examine the relationship among the amount of stress, the perception that stress affects health, and health and mortality outcomes in a nationally representative sample of U.S. adults. METHODS: Data from the 1998 National Health Interview Survey were linked to prospective National Death Index mortality data through 2006. Separate logistic regression models were used to examine the factors associated with current health status and psychological distress. Cox proportional hazard models were used to determine the impact of perceiving that stress affects health on all-cause mortality. Each model specifically examined the interaction between the amount of stress and the perception that stress affects health, controlling for sociodemographic, health behavior, and access to health care factors. RESULTS: 33.7% of nearly 186 million (unweighted n = 28,753) U.S. adults perceived that stress affected their health a lot or to some extent. Both higher levels of reported stress and the perception that stress affects health were independently associated with an increased likelihood of worse health and mental health outcomes. The amount of stress and the perception that stress affects health interacted such that those who reported a lot of stress and that stress impacted their health a lot had a 43% increased risk of premature death (HR = 1.43, 95% CI [1.2, 1.7]). CONCLUSIONS: High amounts of stress and the perception that stress impacts health are each associated with poor health and mental health. Individuals who perceived that stress affects their health and reported a large amount of stress had an increased risk of premature death.

PURPOSE: This study aimed to determine the health-related quality of life (HRQoL) in mothers of 5-year-old very low birth weight (VLBW) and normal birth weight (NBW) children, with a focus on the role of stress. METHODS: This cohort study is ancillary to the Newborn Lung Project. A telephone interview collected information on symptoms of stress and HRQoL from 297 mothers of VLBW children and 290 mothers of NBW children who were enrolled in the Newborn Lung Project Statewide Cohort Study. Staged multiple regression analyses were used to evaluate the relationship between caregiver status and maternal HRQoL and the role stress played in this relationship. Additional multiple regression analyses were also used to evaluate the correlates of poor maternal HRQoL among VLBW mothers. RESULTS: Mothers of VLBW children experienced worse physical and mental HRQoL than mothers of NBW children. Adjusted analyses showed that physical HRQoL was significantly different between these mothers (β: -1.87, P = 0.001); this relationship was attenuated by maternal stress. Among the mothers of VLBW children, stress significantly contributed to adverse HRQoL outcomes when children were aged five. Child behavior problems at the age of two were also associated with worse subsequent maternal mental HRQoL (β: -0.18, P = 0.004), while each week of neonatal intensive care unit stay was associated with worse physical HRQoL (β: -0.26, P = 0.02). CONCLUSIONS: Caring for a VLBW child is negatively associated with the HRQoL of mothers; this relationship might be, in part, explained by maternal stress. Addressing maternal stress may be an important way to improve long-term HRQoL.

Pregnancy complications and poor birth outcomes can affect the survival and long-term health of children. The preconception period represents an opportunity to intervene and improve outcomes; however little is known about women's mental health prior to pregnancy as a predictor of such outcomes. We sought to determine if and to what extent women's preconception mental health status impacted subsequent pregnancy complications, non-live birth, and birth weight using a nationally representative, population-based sample. We used pooled 1996-2006 data from the nationally-representative Medical Expenditure Panel Survey (MEPS). Poor preconception mental health was defined as women's global mental health rating of "fair" or "poor" before conception. Logistic regression was used to assess the association between preconception mental health and pregnancy complications, non-live birth, and having a low birth weight baby within the follow up period. Poor preconception mental health was associated with increased odds of experiencing any pregnancy complication (AOR 1.40, 95% CI: 1.02-1.92), having a non-live birth (AOR 1.48, 95% CI: 0.96-2.27), and having a low birth weight baby (AOR 1.99, 95% CI: 1.00-3.98), all controlling for maternal age, race/ethnicity, marital status, education, health insurance status, income, and number of children in the household. Significant racial and ethnic disparities exist for pregnancy complications and non-live births, but not for low birth weight. Women's preconception mental health is a modifiable risk factor that stands to reduce the incidence of adverse pregnancy complications and birth outcomes.

OBJECTIVES: We determined whether and to what extent a woman's exposure to stressful life events prior to conception (PSLEs) was associated with preterm birth and whether maternal age modified this relationship. METHODS: We examined 9350 mothers and infants participating in the first wave of the Early Childhood Longitudinal Study, Birth Cohort, a nationally representative sample of US women and children born in 2001, to investigate the impact of PSLEs on preterm birth in the United States. We estimated the effect of exposure on preterm birth with weighted logistic regression, adjusting for maternal sociodemographic and health factors and stress during pregnancy. RESULTS: Of the women examined, 10.9% had a preterm birth. In adjusted analyses, women aged 15 to 19 years who experienced any PSLE had over a 4-fold increased risk for having a preterm birth. This association differed on the basis of the timing of the PSLE. CONCLUSIONS: Findings suggest that adolescence may be a sensitive period for the risk of preterm birth among adolescents exposed to PSLEs. Clinical, programmatic, and policy interventions should address upstream PSLEs, especially for adolescents, to reduce the prevalence of preterm birth and improve maternal and child health.

BACKGROUND: The life course perspective suggests a pathway may exist among maternal exposure to stressful life events prior to conception (PSLEs), infant birth weight and subsequent offspring health, whereby PSLEs are part of a 'chains-of-risk' that set children on a certain health pathway. No prior study has examined the link between PSLEs and offspring health in a nationally representative sample of US mothers and their children. We used longitudinal, nationally representative data to evaluate the relation between maternal exposure to PSLEs and subsequent measures of infant and toddler health, taking both maternal and obstetric characteristics into account. METHODS: We examined 6900 mother-child dyads participating in 2 waves of the nationally representative Early Childhood Longitudinal Study-Birth Cohort (n=6900). Infant and toddler health outcomes assessed at 9 and 24 months included overall health status, special healthcare needs and severe health conditions. Adjusted path analyses examined associations between PSLEs, birth weight and child health outcomes. RESULTS: In adjusted analyses, PSLEs increased the risk for very low birth weight (VLBW, <1500 g), which, in turn, predicted poor health at both 9 and 24 months of age. Path analyses demonstrated that PSLEs had small indirect effects on children's subsequent health that operated through VLBW. CONCLUSIONS: Our analysis suggests a chains-of-risk model in which women's exposure to PSLEs increases the risk for giving birth to a VLBW infant, which, in turn, adversely affects infant and toddler health. Addressing women's preconception health may have important downstream benefits for their children, although more research is needed to replicate these findings.

OBJECTIVES: We sought to determine whether the effects of preconception stressful life events (PSLEs) on birth weight differed by neighborhood disadvantage. METHODS: We drew our data from the Early Childhood Longitudinal Study, Birth Cohort (2001-2002; n = 9300). We created a neighborhood disadvantage index (NDI) using county-level data from the 2000 US Census. We grouped the NDI into tertiles that represented advantaged, middle advantaged, and disadvantaged neighborhoods. Stratified multinomial logistic regressions estimated the effect of PSLEs on birth weight, controlling for confounders. RESULTS: We found a gradient in the relationship between women's exposure to PSLEs and having a very low birth weight (VLBW) infant by NDI tertile; the association was strongest in disadvantaged neighborhoods (adjusted odd ratio [AOR] = 1.62; 95% confidence interval [CI] = 1.04, 2.53), followed by middle (AOR = 1.39; 95% CI = 1.00, 1.93) and advantaged (AOR = 1.29; 95% CI = 0.91, 1.82) neighborhoods. We observed a similar gradient for women with chronic conditions and among minority mothers. CONCLUSIONS: Women who experienced PSLEs, who had chronic conditions, or were racial/ethnic minorities had the greatest risk of having VLBW infants if they lived in disadvantaged neighborhoods; this suggests exacerbation of risk within disadvantaged environments. Interventions to reduce rates of VLBW should focus on reducing the deleterious effects of stressors and on improving neighborhood conditions.

The purpose of the study was to understand the association between stressful life events prior to conception (PSLEs) and women's alcohol and tobacco use prior to and during pregnancy, and the continuation of such use through pregnancy. Data were from the Early Childhood Longitudinal Study-Birth Cohort (n = 9,350). Data were collected in 2001. Exposure to PSLEs was defined by indications of death of a parent, spouse, or previous live born child, divorce or marital separation, or fertility problems prior to conception. Survey data determined alcohol and tobacco usage during the 3 months prior to and in the final 3 months of pregnancy. Weighted regressions estimated the effect of PSLEs on alcohol and tobacco use at each time point and on the continuation of use, adjusting for confounders. Experiencing any PSLE increased the odds of tobacco use prior to (adjusted odds ratio [AOR] 1.52, 95 % confidence interval (CI) 1.23-1.87) and during pregnancy (AOR 1.57, 95 % CI 1.19-2.07). Women exposed to PSLEs smoked nearly five additional packs of cigarettes in the 3 months prior to pregnancy (97 cigarettes, p = 0.011) and consumed 0.31 additional alcoholic drinks during the last 3 months of pregnancy than unexposed women. PSLEs are associated with tobacco use before pregnancy and alcohol and tobacco use during pregnancy. Alcohol and tobacco screening and cessation services should be implemented prior to and during pregnancy, especially for women who have experienced PSLEs.

This study takes a lifecourse approach to understanding the factors contributing to delivery methods in the US by identifying preconception and pregnancy-related determinants of medically indicated and non-medically indicated cesarean section (C-section) deliveries. Data are from the Early Childhood Longitudinal Study-Birth Cohort, a nationally representative, population-based survey of women delivering a live baby in 2001 (n = 9,350). Three delivery methods were examined: (1) vaginal delivery (reference); (2) medically indicated C-section; and (3) non-medically indicated C-sections. Using multinomial logistic regression, we examined the role of sociodemographics, health, healthcare, stressful life events, pregnancy complications, and history of C-section on the odds of medically indicated and non-medically indicated C-sections, compared to vaginal delivery. 74.2 % of women had a vaginal delivery, 11.6 % had a non-medically indicated C-section, and 14.2 % had a medically indicated C-section. Multivariable analyses revealed that prior C-section was the strongest predictor of both medically indicated and non-medically indicated C-sections. However, we found salient differences between the risk factors for indicated and non-indicated C-sections. Surgical deliveries continue to occur at a high rate in the US despite evidence that they increase the risk for morbidity and mortality among women and their children. Reducing the number of non-medically indicated C-sections is warranted to lower the short- and long-term risks for deleterious health outcomes for women and their babies across the lifecourse. Healthcare providers should address the risk factors for medically indicated C-sections to optimize low-risk delivery methods and improve the survival, health, and well-being of children and their mothers.