Conversation with Focus

On the Importance of Breastfeeding and Early Childhood Nutrition

As co-principal investigator of the Becoming Breastfeeding Friendly global health initiative, Amber Hromi-Fiedler, Ph.D., M.P.H., has traveled all over the world emphasizing the importance of breastfeeding and nutrition when it comes to maternal and child health. A research scientist in the Department of Social and Behavioral Sciences, she is also the associate director of the Yale School of Public Health’s new Maternal and Child Health Promotion Track.

Focus recently connected with Hromi-Fiedler to discuss Becoming Breast-feeding Friendly, the new Maternal and Child Health Promotion Track and important work she is doing in Ghana.

What is the Becoming Breastfeeding Friendly initiative, and what is the goal of the program?

AH-F: Becoming Breastfeeding Friendly (BBF) is an evidence-informed global initiative that is designed to guide countries in scaling up their national breastfeeding policies and programs. BBF does this by helping countries assess the strength of their breastfeeding-friendly environment, identify gaps, develop recommendations and design plans to scale up their breastfeeding policies and programs. The long-term goal of BBF is to identify and plan which concrete measures a country can take to sustainably increase its breastfeeding rates.

What advantages does breastfeeding provide for infant health, and what is the current prevalence of breastfeeding around the world?

AH-F: There is overwhelming evidence that breastfeeding protects infants from short- and long-term health problems including illnesses (e.g., respiratory infections, ear infections), gastrointestinal problems, overweight/obesity, diabetes. Breastfeeding also protects the mother by reducing her risk for breast cancer, ovarian cancer and Type 2 diabetes. The World Health Organization (WHO) recommends that infants be exclusively breastfed for the first six months, which means that they should not receive anything other than breast milk during that time. However, according to WHO, only 44% of infants under 6 months of age are exclusively breastfed globally.

The new YSPH Maternal and Child Health Promotion Track emphasizes a solution-based approach to improving maternal and child health. Can you tell us more about it?

AH-F: The YSPH Maternal and Child Health Promotion (MCHP) Track was launched in 2021 to provide M.P.H. students with an opportunity to receive training in MCHP. This track takes a different approach from other MCH programs by strengthening student training in implementation science and its application to maternal and child health promotion. Students are required to take three core courses that address implementation science, maternal-child public health nutrition, and women’s and children’s health. Through applied internships, students integrate classroom knowledge with hands-on learning experiences. We spoke with several employers that implement MCH programs and designed this track to help students emerge with strong implementation skills that would be highly attractive to potential employers.

You have collaborated extensively with health professionals in Ghana working to improve nutritional programs for infants and young children. What are the existing nutritional challenges in Ghana, and how is that work going?

AH-F: I am extremely fortunate to have worked for many years conducting MCH research in the Central Region of Ghana with wonderful collaborators from Point Hope Ghana and the University of Ghana. We have focused our work on the Central Region because it is impoverished (34.9% of the population living within the two lowest income quintiles), has the highest perinatal mortality rate of the regions, has high acute and chronic malnutrition rates (14% and 22%, respectively) and almost three-quarters of breastfed children ages 6-23 months lack the minimal acceptable diet. Through our current project, we are trying to understand the best practices to improve exclusive breastfeeding and two important factors influencing child outcomes: meal frequency (how often are children being fed and does it meet global recommendations?) and diet diversity (are children getting diverse foods in their early life?) in the Central Region of Ghana. We are doing this using the Trials of Improved Practices, a formative research approach, to implement a home visiting-based intervention designed to integrate responsive feeding into established infant and young-child feeding training and program delivery. We expect to be finished within the next few months, and at that time, we will know whether this intervention was acceptable and feasible to the mothers and health care providers who participated.

On the Power of Statistics and Improving Reproductive Health

Heping Zhang’s pioneering work in the fields of epidemiology, statistics and reproductive health has garnered international attention and acclaim. This year, Zhang, Ph.D., the Susan Dwight Bliss Professor of Biostatistics at the Yale School of Public Health, will deliver the prestigious Neyman Lecture at the Institute of Mathematical Statistics’ annual meeting in London, one of the highest honors in statistical societies. The author of more than 300 research publications, Zhang is perhaps best known in medicine for his work with infertility. He served as a principal investigator on a collaborative study that found the infertility drug letrozole was more effective than clomiphene citrate in helping women with polycystic ovary syndrome (PCOS). The findings, released in 2014, dramatically changed how doctors treat millions of patients with PCOS experiencing fertility problems. In a separate study two years later, Zhang and colleagues found that frozen embryos rather than fresh ones for in vitro fertilization may improve the chances of a successful pregnancy in women diagnosed with PCOS, another major advancement in reproductive science.

As the director of Yale’s Collaborative Center for Statistics in Science, Zhang has been an international leader in fostering research collaborations that are applying innovative statistical methods to address complex issues in public health, including infertility.

Focus recently asked Dr. Zhang, who is also a professor in the Yale Child Study Center and professor of statistics and data science, to share his thoughts on the power and potential of statistical methods and data science for improving maternal and child health.

The tremendous amount of health data being generated today has created an enormous opportunity for scientists to better understand diseases and develop new treatments and prevention strategies. How is your research in biostatistics contributing to this effort?

HZ: The availability of a large amount of health data is tremendously helpful to statisticians and scientists in general. We have two NIH-funded research projects that make use of such data, first, as the benchmark to develop better analytic methods and software that can be used broadly to understand the etiologies of diseases and human development, particularly as it pertains to genetic mechanisms and gene-environment interaction; and second, to aid in the discovery of novel results related to specific disorders, including COVID-19-related mortality and cognition. Also importantly, I have led the data coordinating centers for several large national and international research consortiums in reproductive health, which have generated large-scale and high-quality data. Those data are available for public use. So, our contributions are threefold: (1) generating and sharing data; (2) analyzing available data to better understand specific human conditions; and (3) developing tools for everyone to analyze similar data.

Much of your work is associated with the fields of medicine and health. Yet, you have been quick to point out that you are a statistician, not a clinician. Can you please explain how those two roles differ when it comes to the work that you do?

HZ: If I were a clinician, I would have firsthand information in diagnosing and treating patients and an understanding of what treatments work best for them. This knowledge and expertise is essential to knowing the most pressing issues that patients face and what research is necessary to resolve those issues. As a statistician, through research and collaboration, I have a good understanding of issues in medicine and health, yet I don’t have the day-to-day knowledge and expertise of a clinician. When the patients’ information comes to me, the human aspect is “de-identified” and detached. The focus of my responsibility is to understand the data. Who contributed the data is irrelevant to me. As a statistician, my research is designed to help the general population rather than specific individual patients.

You have organized and led scientific collaborations around the world. How important is collaboration in the fields of biostatistics, statistics and data science?

HZ: I have colleagues in statistics and biostatistics who have built successful careers using mathematics and computers without in-depth collaborations with health scientists. So, collaborations are not the only avenue to be successful in the fields of biostatistics, statistics and data science. That being said, in this era of data science, collaborations are essential if we want to resolve the most impactful problems in medicine and health.

You recently published a study with colleagues from the University of Minnesota that shed new light on potential fertility treatments for women with PCOS. What did you find?

HZ: That was a paper with three of my former postdoctoral students. The work began a few years ago, and those students are now faculty members at other universities. It was really a Yale-based study. We analyzed existing data from PCOS women using a more efficient analytic approach that considers the special relationship between ovulation, conception, and live birth, in that a later event happens only if the earlier ones did. As a result, we were able to accommodate more data in our analysis. For example, in an RMN trial published by the New England Journal of Medicine in 2017, letrozole was found to be overall more effective than clomiphene. Our new analysis suggests that the effectiveness of clomiphene in older women warrants further investigation.

On Obesity and Maternal and Child Health

Associate Professor Nicola Hawley, Ph.D., leads a variety of innovative research projects within Pacific Islander communities, which have been identified as some of the most at-risk for adverse, obesity-related health outcomes globally. A member of the Epidemiology (Chronic Disease) Department, Hawley focuses her research primarily on improving maternal and child health and preventing obesity-related chronic disease in resource-poor, low-income settings.

Focus connected with Hawley recently to discuss the impact of obesity on maternal and early childhood health, her ongoing work and some of the innovative solutions she is pursuing to address the problem.

What health risks do woman who are overweight or considered obese face during and after pregnancy?

NH: Women who have overweight or obesity when they become pregnant have greater risk of a number of complications compared to women without overweight/obesity. They might experience gestational diabetes, gestational hypertension or preeclampsia (a severe form of pregnancy high blood pressure). There are also risks of preterm birth, macrosomia—where the baby is larger than normal—and stillbirth. Because of some of these complications, the risk of having a Caesarean-section birth is also greater, making postpartum recovery more challenging.

Much of your research is taking place in the Pacific Islands and American Samoa. What is the situation there in terms of obesity, diabetes and maternal and child health, and are things getting better or worse?

NH: The Pacific Islands are continuing to experience an epidemic of noncommunicable diseases (diabetes, cardiovascular diseases, cancer), many of which are related, at least in part, to overweight or obesity. This is presenting real challenges for those working in maternal and child health. In many low-resource settings, providers and policymakers are still addressing the fundamentals of maternal and child health: increasing the number of women who receive prenatal care, ensuring that women have access to skilled birth attendants and making sure that emergency obstetric care is available. Now they are also dealing with increasing incidence of diabetes and high blood pressure in pregnancy, which is leading to worsening maternal and child outcomes. There is a real need to rethink the way that care is delivered before, during and after pregnancy that addresses these issues in a holistic way.

You are the principal investigator for the Samoan Obesity, Lifestyle and Genetic Adaptations Study Group, or OLaGA (meaning “Life” in Samoan). What is the group’s purpose and goal?

NH: As the Samoan name suggests, the group’s goal is to look at every aspect of the life course, from birth to old age, to see what leads some people to be at risk of overweight or obesity and related diseases, while others are not. By learning what the most important risk factors are at any given age, the hope is that we will be able to tailor intervention approaches to better prevent and treat obesity. The expertise of the faculty and students who are involved in the group spans genetic epidemiology to nutrition to psychosocial well-being to intervention development and health service delivery, and all have the same goal of improving the health of this underrepresented, at-risk group.

Your Ola Tuputupua’e (Growing Up) study in Samoa has received significant attention. What is the focus of that research?

NH: The Ola Tuputupua’e study is very special. It is the first cohort study, following the same families over time, to have been established in any Pacific Island nation outside of New Zealand. More than 500 families have been enrolled for seven years now and graciously give us their time every two years so that we can check in on their children’s health. We have learned a lot about what puts children at risk of obesity, high blood pressure and hyperglycemia, including some things you might expect, like poor diet quality. By following children over time, we have also been able to uncover some new information about the persistently high levels of anemia that are seen in many Pacific islands. What is really amazing about this study, though, is that it was established by a Yale M.P.H. student, Courtney Choy, in 2015 and has been almost entirely student-resourced since then, proof that our students do incredible, important work.

You have been testing some creative solutions to addressing obesity and maternal and child health through your Strong Together Raising Our Next Generation (STRONG) study in American Samoa. What are some of the interventions that you are applying and are they proving impactful?

NH: We recently completed a pilot study of STRONG, which used a group prenatal care curriculum developed here at Yale by Jeannette Ickovics and others. Women randomized to the group care intervention, which had a weight control focus, gained almost 4.5 kg [10 pounds] less weight during their pregnancies, were less likely to develop gestational diabetes, and breastfed longer than women receiving standard care. We are hoping to scale that study to make group care available to everyone in the territory soon. We were just awarded a grant from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) that will allow us to do some new work with adolescents to see if they can serve as agents of change among their own families and promote better diabetes-related outcomes. All of the interventions draw on the existing strengths of the American Samoan community, and so far, have generated a lot of excitement locally.

Can you share with us some of the other areas of maternal and child health research that you are pursuing or hope to pursue in the near future?

NH: Much of my work to date has been in the Pacific Islands or the U.S.-affiliated Pacific territories. A major current focus is bringing that work back to the Pacific Islander communities here in the U.S. who are under-represented and experience major perinatal health disparities. One of my Ph.D. students, Bohao Wu, has been documenting some of the disparities in preterm birth between Pacific Islanders and other populations. We are looking forward to developing interventions to address the issue.

861 women in the United States died as a result of pregnancy or delivery complications in 2020. The U.S. Centers for Disease Control and Prevention reports thattwo out of three of these deaths are preventable.

2 out of 3 preventable deaths.

Maternal Mortality Rates in the United States, 2020
Centers for Disease Control & Prevention