Author ORCID Identifier

https://orcid.org/0000-0002-6432-9185

Semester

Spring

Date of Graduation

2026

Document Type

Dissertation

Degree Type

PhD

College

School of Public Health

Department

Epidemiology

Committee Chair

Bethany Barone Gibbs

Committee Member

Christa L. Lilly

Committee Member

Amna Umer

Committee Member

Kara M. Whitaker

Abstract

Introduction: Cardiovascular diseases are a leading cause of pregnancy-related deaths in the United States, with higher rates in rural areas. While limited healthcare access contributes to this disparity, other factors remain unclear. Breastfeeding provides long-term protection against cardiovascular disease, but modern infant feeding practices are complex and may impact maternal cardiovascular health (CVH) in unexpected ways. Healthy CVH behaviors of sufficient sleep duration, adequate physical activity, a healthy diet, and nicotine avoidance can enhance protection against future cardiovascular disease risk. Therefore, the aims of this dissertation are to 1) assess associations between rurality and first trimester CVH behaviors; 2) synthesize existing research and identify knowledge gaps regarding breastfeeding and maternal postpartum CVH behaviors; and 3) examine the association between infant feeding practices and postpartum CVH behaviors.

Methods: The first aim analyzed the Mountain Mama and Baby Study cohort (n=367), where rurality was operationalized with Rural-Urban Commuting Area Codes and CVH behaviors were measured with questionnaires. CVH behaviors were scored using the American Heart Association’s (AHA) Life’s Essential 8 algorithm. Logistic regression models evaluated the associations between rurality and CVH behaviors. For the second aim, a scoping review was conducted according to the Joanna Briggs Institute (JBI) methodology and the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) – Scoping Review checklist. In the third aim, infant feeding practices were assessed using a questionnaire, and CVH outcomes were quantified with both devices and self-report in the Postpartum 24/7 cohort (n=48). A CVH behavior score was calculated using the AHA algorithm. Linear mixed-effects models examined associations across time, and multiple linear regression assessed cross-sectional associations. 

Results: In the pregnancy cohort study, participants in Rural-Micropolitan and Rural-Small Towns areas had higher odds of overall low/moderate CVH behavior (aOR=2.0, 95% CI: 1.1,3.4; aOR=2.5, 95% CI: 1.3, 4.9, respectively) and nicotine exposure (aOR=2.1, 95% CI 1.1, 4.0; aOR=2.2, 95% CI 1.1, 4.6) compared with Urban-Metropolitan residents. The scoping review included 60 studies and found that breastfeeding was associated with longer and better-quality sleep, higher energy intake and dietary quality, and lower smoking or smoking relapses.  Associations between breastfeeding and sleep efficiency, as well as breastfeeding and physical activity, were mixed. In the postpartum cohort study, infant feeding method and total time feeding were not associated with CVH behaviors (all p≥0.05). Compared with exclusive maternal breast milk, exclusive infant formula was associated with higher diet adherence at 3 months (Est.=3.1, p≤0.001) but lower CVH behavior scores at 6 (Est.=-8.7, p=0.001) and 12 months (Est.=-5.3, p=0.05). At 6 months, mixed feeding was associated with shorter sleep duration (Est.=-0.7, p=0.02).

Discussion: Suboptimal CVH behaviors during pregnancy may contribute to the persistence of rural health disparities. Available research indicates that breastfeeding is associated with better sleep, diet quality, and smoking behaviors postpartum, yet evaluations of associations with physical activity were limited. Our follow-up investigation found that infant feeding methods and time feeding were not consistently associated with postpartum CVH behaviors, though some associations with CVH behavior scores, sleep duration, and diet adherence were observed at specific time points. This dissertation suggests that promoting CVH behaviors is a potential intervention strategy for reducing rural disparities in pregnancy-related morbidity and mortality as well as increased understanding about the complex relationships between infant feeding practices and maternal CVH behaviors

Download

Share

COinS