Fruits of labor
Associate Professor Linda Bullock works to keep infants safer by encouraging their mothers to quit smoking.
Bolstered by almost $3 million from the National Institutes of Health, Associate Professor Linda Bullock is working to improve the health of babies in violent homes.
Bullock’s previous research focused on the stresses facing low-income women. This study, which is in the final phase of data analysis, examines how stress fuels the urge to smoke among pregnant, low-income women and tests a simple intervention designed to help provide a degree of stress-relieving social support that could help the women quit smoking and provide better birth outcomes as a result.
The project is known as “Baby BEEP,” for Behavioral Educational Enhancement in Pregnancy, and the preliminary results are encouraging.
Yet as Bullock made headway in improving infant health by helping mothers stop smoking, she noticed a disturbing trend. More than one in three of the Baby BEEP participants were victims of domestic violence, a major source of stress that contributed to their desire to light up.
“Low-income women and their infants are already at risk for negative health outcomes,” Bullock states, “and the alarmingly high rate of intimate partner violence (IPV) among pregnant and postpartum women further threatens both women’s and infants’ health.”
Baby BEEP involves a team of nurses who call low-income, mostly rural, pregnant women weekly to offer a listening ear, a shoulder to cry on and referrals to sources of help when needed. For many of the women, struggling to kick the cigarette habit for the health of their babies, the weekly phone calls became a lifeline.
But the nurses on the other end couldn't’t ignore the disturbing reports many of the subjects related. Data collected about halfway through the Baby BEEP study period indicated that more than 30 percent of the women were abused before and/or during their pregnancies.
With her sample of Medicaid-eligible women already selected for Baby BEEP, Bullock designed a second study and called it “Baby BEEP for Kids.”
“We know that battered women are more likely to smoke during pregnancy,” Bullock says. “There’s probably about a 25 percent rate of IPV among low-income women in general.” She adds that an additional 5 to 12 percent are abused during pregnancy while 25 percent report abuse prior to pregnancy. “The rates depend on how you look at the sample—but it’s still high,” she says.
Bullock’s new NIH grant provides four years of funding and she is ready to go. She recruited Baby BEEP for Kids participants as early as last year.
“We already had a subject pool,” Bullock says, explaining the women who complete Baby BEEP are eligible to participate in Baby BEEP for Kids. “We know the women receiving telephone support in Baby BEEP were less stressed and depressed and the literature tells us that they’ll probably be better mothers as a result.”
Yet the Baby BEEP intervention the participants relied on finished at six weeks postpartum. Those continuing in the two-year Baby BEEP for Kids are re-randomized into groups, with only half receiving the phone intervention. In order to recruit the more than 300 women needed for Baby BEEP for Kids from the Baby BEEP subject pool, Bullock has expanded the original Baby BEEP study to almost 700 women.
While the Baby BEEP for Kids study design follows its predecessor, Bullock didn't’t anticipate the response of women who were randomized to the Baby BEEP for Kids control group—the ones who will not receive the weekly phone call.
Those who had experienced the intervention during Baby BEEP were sold on it and a few had trouble accepting an assignment to the Baby BEEP for Kids control group. Some even call the Baby BEEP nurses on their own accord because they feel the need to continue the relationship.
“One woman calls like clockwork every week,” Bullock says. “She’s continuing the intervention on her own, which tells us a lot about the fact that what we did during their pregnancies has built a strong rapport that these women need.”
And some women who are now pregnant for a second time since their initial role in Baby BEEP have expressed disappointment at not being able to participate in the study twice.
This determined desire to receive the Baby BEEP intervention may be somewhat surprising when one considers the phone calls include no specific medical or legal advice.
“It is minimal support,” Bullock explains.“The nurses basically act as a next-door neighbor. They try to get the women to talk about themselves and about their babies.”
In Baby BEEP for Kids, the nurses listen for clues about the infants’ developmental progress. However, their role is limited to that of a good listener who can suggest resources and provide health promotion education.
In cooperation with Bullock, Kevin Everett, assistant professor of Family and Community Medicine at the MU School of Medicine, is using his expertise in psychological counseling to help Bullock’s research staff hone their listening skills.
Everett’s research, which uses a technique known as “motivational interviewing” to help expectant and new fathers stop smoking, dovetails with Bullock’s in terms of a focus on family dynamics and health.
“I try to help moms and babies,” Bullock says. “Kevin tries to help fathers. Eventually we want to combine forces to improve the health of the entire family unit.”
It may seem unusual that women in small towns would lack social support, given the stereotype of small-town neighbors leaning over fences to chat and making casseroles for the sick. Yet Bullock notes that the violence many of the women in her study report is one contributor to a lack of social network.
“Men who batter women isolate their victims,” she says. As a result many of the women become estranged from their families and friends.
“These are people who have struggled all their lives,” she adds. “Plus most of their friends are as stressed out as they are.”
Another cause of stress felt by the Baby BEEP participants is the poverty these women face. “Because of the poverty, these women often feel and respond differently from middle class norms,” Bullock explains. “Our staff has had to learn to work with that.”
For instance, many of the women in the Baby BEEP studies leave their television sets on all day, regardless of what is happening in their house.
“The TV masks a lot of turbulence,” Bullock says. “Parking the kids in front of the TV becomes a real issue. There are so many problems—nutrition, poor sleep habits— it’s hard to know what to work on and how to help the women deal with things.”
But the issue of violence stands out, and Bullock is determined to encourage subjects to deal with the situation. Her staff, trained in domestic violence protocols, assists women on developing strategies to keep themselves and their children safe even if they stay with their abusers. They offer a toll-free number that provides free counseling. And, when needed, they help the women plan an escape.
While Bullock’s staff strives to help the women in the study, another focal point must be placed on the children. Even if a child is not abused, exposure to an abusive relationship has tremendous impact. Children from abusive households often act out, have difficulty concentrating and experience emotional problems.
The Baby BEEP for Kids study assesses children at 6, 15 and 24 months of age to track their development using various screening tools. Among the issues being assessed by a research team member hired just for this purpose are the children’s attachments, the mothers’ responsiveness and parenting stress.
Bullock hopes if the studies are successful, her simple intervention can serve as a model for health systems and providers.
“I know our nurses are making a difference with the women—making them better citizens and better mothers,” Bullock says. “Even if it’s just one woman, I feel it’s a success.”