Aleeca Bell

Interests

Research

My clinical experience as a Certified Nurse Midwife drives my bio-behavioral research questions. My program of research strives to improve the wellbeing of mothers and infants by promoting physiologic birth, a positive birth experience, healthy mother-infant interaction, and an increased understanding of underlying biologic mechanisms. The oxytocin system is a biological metaphor for feeling safe and cared for; and can be a target of innovative interventions and evidence-based practice to improve the health and well-being of vulnerable women and infants in the perinatal period. My R01 grant from the National Institute of Nursing Research (2020-2025) was an RCT that targeted mothers with a history of childhood adversity to promote mother-infant synchrony. Synchrony is when the actions of one affects the actions of the other in a coordinated manner that is mutually rewarding, and promotes bonding and infant development. To improve synchrony, we tested a low cost, early life, multisensory behavioral intervention that is easy for mothers to learn and apply with their infant. We also determined whether the intervention improves epigenetic regulation of the oxytocin system, since oxytocin function facilitates engaged social interaction (e.g., bonding, empathy, positive affect) and is highly susceptible to early life adversity. The study's primary findings are currently in the dissemination phase of publications and scientific conference presentations. Future studies will investigate 1) the implementation of clinicians or peer mentors teaching the intervention to mothers, and 2) expanding the intervention to additional vulnerable populations, such as women with depression or who suffered a traumatic birth experience.

Courses

Scholarly Contributions

Journals/Publications

• Erickson, E., Bell, A., Weinstein, S. R., & Boyles, S. (2025).

  Postpartum Hemorrhage and the Likelihood of Exclusive Breastfeeding through Six Months Postpartum: A Case-Control Study.

  . Journal of Midwifery & Women's Health.
• Kim, H., Bell, A., Park, C. G., Snyder, M. D., Mathews, A. K., White-Traut, R., & Rutherford, J. N. (2025). Neighborhood Environment and Mother-Infant Interaction: Considering the Roles of Maternal Psychological Distress and Social Support. Journal of Child and Family Studies, 34(Issue 8). doi:10.1007/s10826-025-03086-z
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  The quality of mother-infant (MI) interaction is vital to optimal child development and neighborhood environment has emerged as an important contextual factor linked to MI interaction. However, less attention has been given to understanding the mechanisms underlying the association between neighborhood environment and MI interaction through maternal psychological distress or social support. Therefore, we investigated associations between neighborhood environment (surrounding neighborhood characterized by safety and low noise level) and MI interaction and the potential mediating roles of maternal psychological distress (maternal depressive and anxiety symptoms) and social support. The data for this study (N = 949 MI dyads, infant mean age: 7.6 months) were obtained from the Family Life Project (FLP) conducted in rural areas of North Carolina and Pennsylvania from 2003 to 2008. FLP’s home visitors evaluated neighborhood environment during a 6-month home visit, while mothers completed questionnaires assessing depression, anxiety, and social support. MI interaction was observed during free-play interaction. Structural equation modeling was employed to test the direct effect of neighborhood environment on MI interaction and the effects of the hypothesized mediators on this relationship. Findings indicated that neighborhood environment had a positive direct effect on MI interaction; maternal psychological distress and social support did not mediate the relationship. The results suggest the importance of contextual factors on MI interaction that extend beyond women’s maternal behaviors. To enhance the quality of MI interaction, public policies should aim to improve neighborhood conditions for mothers and infants.
• Kim, H., Park, C. G., Matthews, P. A., Bell, A., White-Traut, R., & Rutherford, J. N. (2025).

  Neighborhood environment and mother-infant interaction: the mediating roles of maternal psychological distress and social support

  . Journal of Child and Family Studies.
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  This is the dissertation work of Dr. Kim. I chaired her committee. I contributed to study design, data interpretation, and manuscript preparation.Submitted in Fall of 2023, for 2024 publication
• MacLean, E. L., Carranza, E., Gnanadesikan, G. E., King, K. M., Allen, A. M., Linde-Krieger, L. B., Feldman, R., White-Traut, R. C., Hammock, E. A., Carter, C. S., Leng, G., Tecot, S. R., & Bell, A. F. (2024).

  Neurophysin I is an analytically robust surrogate biomarker for oxytocin

  . Psychoneuroendocrinology, 161, 106951.
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  Oxytocin is a pleiotropic neuropeptide that plays roles in biological processes ranging from birth, lactation, and social bonding to immune function, cardiovascular repair, and regulation of appetite. Although measurements of endogenous oxytocin concentrations have been performed for more than 50 years, the ability to measure oxytocin accurately poses notable challenges. One potential solution for overcoming these challenges involves measurement of oxytocin's carrier molecule - neurophysin I (NP-1) - as a surrogate biomarker. NP-1 is secreted in equimolar concentrations with oxytocin but has a longer half-life, circulates in higher concentrations, and can be measured using a sandwich immunoassay. We report experiments that 1) analytically validate a commercially available NP-1 sandwich immunoassay for use with human plasma and urine samples, 2) confirm the specificity of this assay, based on detection of NP-1 in plasma from wild-type but not oxytocin knockout mice, 3) demonstrate that NP-1 concentrations are markedly elevated in late pregnancy, consistent with studies showing substantial increases in plasma oxytocin throughout gestation, and 4) establish strong correlation between NP-1 and plasma oxytocin concentrations when oxytocin is measured in extracted (but not non-extracted) plasma. The NP-1 assay used in this study has strong analytical properties, does not require time-intensive extraction protocols, and the assay itself can be completed in
• MacLean, E. L., Carranza, E., Gnanadesikan, G. E., King, K. M., Allen, A. M., Linde-Krieger, L. B., Feldman, R., White-Traut, R. C., Hammock, E. A., Carter, C. S., Leng, G., Tecot, S. R., & Bell, A. F. (2024). Neurophysin I is an analytically robust surrogate biomarker for oxytocin. Psychoneuroendocrinology, 161, 106951.
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  Oxytocin is a pleiotropic neuropeptide that plays roles in biological processes ranging from birth, lactation, and social bonding to immune function, cardiovascular repair, and regulation of appetite. Although measurements of endogenous oxytocin concentrations have been performed for more than 50 years, the ability to measure oxytocin accurately poses notable challenges. One potential solution for overcoming these challenges involves measurement of oxytocin's carrier molecule - neurophysin I (NP-1) - as a surrogate biomarker. NP-1 is secreted in equimolar concentrations with oxytocin but has a longer half-life, circulates in higher concentrations, and can be measured using a sandwich immunoassay. We report experiments that 1) analytically validate a commercially available NP-1 sandwich immunoassay for use with human plasma and urine samples, 2) confirm the specificity of this assay, based on detection of NP-1 in plasma from wild-type but not oxytocin knockout mice, 3) demonstrate that NP-1 concentrations are markedly elevated in late pregnancy, consistent with studies showing substantial increases in plasma oxytocin throughout gestation, and 4) establish strong correlation between NP-1 and plasma oxytocin concentrations when oxytocin is measured in extracted (but not non-extracted) plasma. The NP-1 assay used in this study has strong analytical properties, does not require time-intensive extraction protocols, and the assay itself can be completed in
• MacLean, E. L., Carranza, E., Gnanadesikan, G. E., King, K. M., Allen, A. M., Linde-Krieger, L. B., Feldman, R., White-Traut, R. C., Hammock, E. A., Carter, C. S., Leng, G., Tecot, S. R., & Bell, A. F. (2024). Neurophysin I is an analytically robust surrogate biomarker for oxytocin. Psychoneuroendocrinology, 161. doi:10.1016/j.psyneuen.2023.106951
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  Oxytocin is a pleiotropic neuropeptide that plays roles in biological processes ranging from birth, lactation, and social bonding to immune function, cardiovascular repair, and regulation of appetite. Although measurements of endogenous oxytocin concentrations have been performed for more than 50 years, the ability to measure oxytocin accurately poses notable challenges. One potential solution for overcoming these challenges involves measurement of oxytocin's carrier molecule – neurophysin I (NP-1) – as a surrogate biomarker. NP-1 is secreted in equimolar concentrations with oxytocin but has a longer half-life, circulates in higher concentrations, and can be measured using a sandwich immunoassay. We report experiments that 1) analytically validate a commercially available NP-1 sandwich immunoassay for use with human plasma and urine samples, 2) confirm the specificity of this assay, based on detection of NP-1 in plasma from wild-type but not oxytocin knockout mice, 3) demonstrate that NP-1 concentrations are markedly elevated in late pregnancy, consistent with studies showing substantial increases in plasma oxytocin throughout gestation, and 4) establish strong correlation between NP-1 and plasma oxytocin concentrations when oxytocin is measured in extracted (but not non-extracted) plasma. The NP-1 assay used in this study has strong analytical properties, does not require time-intensive extraction protocols, and the assay itself can be completed in < 2 h (compared to 16–24 h for a competitive oxytocin immunoassay). Our findings suggest that much like copeptin has become a useful surrogate biomarker in studies of vasopressin, measurements of NP-1 have similar potential to advance oxytocin research.
• Maeder, A. B., Bell, A. F., McFarlin, B. L., Park, C. G., Kominiarek, M. A., Toledo, P., Carter, C. S., Nazarloo, H., & Vonderheid, S. C. (2024). Feasibility Study to Compare Oxytocin Function Between Body Mass Index Groups at Term Labor Induction. JOGNN - Journal of Obstetric, Gynecologic, and Neonatal Nursing, 53(Issue 2). doi:10.1016/j.jogn.2023.11.003
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  Objective: To determine the feasibility of a protocol to examine the association between oxytocin system function and birth outcomes in women with and without obesity before induction of labor. Design: Prospective descriptive. Setting: Academic medical center in the U.S. Midwest. Participants: Pregnant women scheduled for induction of labor at 40 weeks of gestation or greater (n = 15 normal weight; n = 15 obese). Methods: We collected blood samples and abstracted data by chart review. We used percentages to examine adherence to protocol. We used t tests and chi-square tests to describe differences in sample characteristics, oxytocin system function variables, and birth outcomes between the body mass index groups. Results: The recruitment rate was 85.7%, protocol adherence was 97.1%, and questionnaire completion was 80.0%. Mean plasma oxytocin concentration was higher in the obese group (M = 2774.4 pg/ml, SD = 797.4) than in the normal weight group (M = 2193.5 pg/ml, SD = 469.8). Oxytocin receptor DNA percentage methylation (CpG −934) was higher in the obese group than in the normal weight group. Conclusion: Our protocol was feasible and can serve as a foundation for estimating sample sizes in forthcoming studies investigating the diversity in oxytocin system measurements and childbirth outcomes among pregnant women in different body mass index categories.
• Grisham, L. M., Rankin, L., Maurer, J. A., Gephart, S. M., & Bell, A. F. (2023). Scoping Review of Biological and Behavioral Effects of Babywearing on Mothers and Infants. Journal of obstetric, gynecologic, and neonatal nursing : JOGNN, 52(3), 191-201.
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  To synthesize the evidence on the biological and behavioral effects of babywearing on mothers and infants.
• Weinstein, S. R., Erickson, E. N., Molina, R., & Bell, A. F. (2023). Maternal outcomes related to Genetic and epigenetic Variation in the oxytocin system: A scoping review. Comprehensive psychoneuroendocrinology, 16, 100209.
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  In this scoping review, we synthesize the literature on oxytocin and oxytocin receptor genetic and epigenetic variation in relationship to breastfeeding, maternal caregiving behavior, and maternal mental health.
• Maeder, A. B., Park, C. G., Vonderheid, S. C., Bell, A. F., Carter, C. S., & Mcfarlin, B. L. (2020). Maternal and system characteristics, oxytocin administration practices, and cesarean birth rate.. Birth (Berkeley, Calif.), 47(2), 220-226. doi:10.1111/birt.12482
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  The cesarean birth rate in the United States is 32%, and there is discussion about the cause of high surgical birth rates. Our purpose was to determine whether mode of birth is influenced by maternal, nurse, and system factors..Secondary analysis of a data set of 163 women having postdates labor induction with oxytocin. Kaplan-Meier survival curves were calculated to compare the time for patients to reach an infusion rate of 6 mU/min, consistent with endogenous oxytocin levels in active labor. We used the log-rank test to evaluate survival curve differences. Multiple logistic regression and Cox proportional hazards models were conducted and included covariates that had statistically significant bivariate relationships with the time variable, or were clinically meaningful..The mean time to reach 6 mU/min was longer for women who birthed by cesarean (172.5 minutes) than for women who had vaginal birth (125.0 minutes, P = .024). The mean time to reach 6 mU/min was also longer for women admitted on night shift (147.0 minutes) than day shift (110.2 minutes, P = .018). No maternal characteristics were significantly related to the time to reach a rate of 6 mU/min..Even during the initial hours of labor induction, it is important that the oxytocin infusion is titrated appropriately to aid women in achieving timely vaginal birth. Intrapartum nurses should receive education about the pharmacokinetics of intravenous oxytocin to understand proper administration of this high-alert medication.
• Narapareddy, L., Wildman, D. E., Armstrong, D. L., Weckle, A., Bell, A. F., Patil, C. L., Tardif, S. D., Ross, C. N., & Rutherford, J. N. (2020). Maternal weight affects placental DNA methylation of genes involved in metabolic pathways in the common marmoset monkey (Callithrix jacchus). American Journal of Primatology, 82(Issue 3). doi:10.1002/ajp.23101
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  Accumulating evidence suggests that dysregulation of placental DNA methylation (DNAm) is a mechanism linking maternal weight during pregnancy to metabolic programming outcomes. The common marmoset, Callithrix jaccus, is a platyrrhine primate species that has provided much insight into studies of the primate placenta, maternal condition, and metabolic programming, yet the relationships between maternal weight and placental DNAm are unknown. Here, we report genome-wide DNAm from term marmoset placentas using reduced representation bisulfite sequencing. We identified 74 genes whose DNAm pattern is associated with maternal weight during gestation. These genes are predominantly involved in energy metabolism and homeostasis, including the regulation of glycolytic and lipid metabolic processes pathways.
• Bell, A., Rubin, L., Davis, J., Golding, J., Adejumo, O., & Carter, C. (2019). The birth experience and subsequent maternal caregiving attitudes and behavior: a birth cohort study. Archives of Women's Mental Health, 22(5). doi:10.1007/s00737-018-0921-3
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  Optimal maternal caregiving is critical for children’s healthy development, yet quality of maternal caregiving may be influenced by a negative birth experience. We examined whether the birth experience was associated with maternal caregiving attitudes and behavior throughout the first year. We conducted secondary analysis of the Avon Longitudinal Study of Parents and Children birth cohort on perinatal data. The birth experience was assessed using self-report data on level of support in labor. Maternal caregiving variables were self-report maternal attitudes at one and eight postnatal months, and observed maternal behavior at 12 postnatal months. Data were analyzed using multivariable logistic regression models adjusting for critical covariates at one (N = 4389), eight (N = 4580), and 12 (N = 842) postnatal months. Feeling supported in labor was associated with a report of “immediately falling in love” with one’s baby after birth, surveyed at 1 month (adjusted OR 1.41 [95% CI 1.20–1.65]), and with more positive parenting scores at 8 months (adjusted OR 1.56 [95% CI 1.36–1.79]), but not with more positive observed maternal behavior at 12 months. Additional risk factors were identified. Our findings suggest that we may be able to modify the risk of poor postnatal maternal caregiving by supporting women in labor and facilitating a positive birth experience.
• Griffith, T. T., Bell, A. F., Vincent, C., White-Traut, R., Medoff-Cooper, B., & Rankin, K. (2019). Oral Feeding Success: A Concept Analysis. Advances in Neonatal Care, 19(Issue 1). doi:10.1097/anc.0000000000000540
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  Background: The term "oral feeding success" (OFS) is frequently used in clinical practice and research. However, OFS is inconsistently defined, which impacts the ability to adequately evaluate OFS, identify risk factors, and implement interventions in clinical practice and research. Purpose: To develop the defining attributes, antecedents, and consequences for the concept of OFS in preterm infants during their initial hospitalization. Methods: PubMed, CINAHL, and PsycINFO databases were searched for English articles containing the key words "oral feeding success" and "preterm infants." The Walker and Avant method for concept analysis was employed. Results: Sixteen articles revealed the defining attributes, antecedents, and consequences. Defining attributes included (1) physiologic stability; (2) full oral feeding; and (3) combined criteria of feeding proficiency (≥30% of the prescribed volume during the first 5 minutes), feeding efficiency (≥1.5 mL/min over the entire feeding), and intake quantity (≥80% of the prescribed volume). Implications for Practice: The 3 defining attributes may be used in clinical practice to consistently evaluate OFS. The antecedents of OFS provide clinicians with a frame of reference to assess oral feeding readiness, identify risk factors, and implement effective interventions. The consequences of OFS allow clinicians to anticipate challenges when OFS is not achieved and create a care plan to support the infants. Implications for Research: The empirical referents of OFS provide consistent and clear operational definitions of OFS for use in research. The antecedents and consequences may guide researchers to select specific measures or covariates to evaluate valid measures of OFS.
• Griffith, T. T., Bell, A. F., White-Traut, R., Medoff-Cooper, B., & Rankin, K. (2018). Relationship Between Duration of Tube Feeding and Success of Oral Feeding in Preterm Infants. JOGNN - Journal of Obstetric, Gynecologic, and Neonatal Nursing, 47(Issue 5). doi:10.1016/j.jogn.2018.06.002
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  Objective: Primary: to identify the potential relationship between duration of tube feeding and success of oral feeding in preterm infants; secondary: to identify the potential relationships among duration of tube feeding and alert behavioral states, orally directed behaviors, and nutritive sucking. Design: A descriptive correlational study. Setting: A Level III NICU at an inner-city hospital. Participants: Twenty-eight preterm infants who were born between 28 and 32 weeks gestational age, were clinically stable, and were expected to have at least 1 week of tube feeding during their initial hospitalizations. Methods: Data were collected daily from participants’ electronic medical records and at one-time oral feeding evaluations within 48 hours after the removal of the feeding tube. Results: We found a significant negative correlation between duration of tube feeding and oral feeding success (p =.000). We found no correlations between duration of tube feeding and alert behavioral states, orally directed behaviors, or nutritive sucking. Conclusion: Although the duration of tube feeding is a nonmodifiable factor, preterm infants who are anticipated to have extended durations of tube feeding may be at risk for delayed oral feeding success.
• Ruchob, R., Rutherford, J. N., & Bell, A. F. (2018). A Systematic Review of Placental Biomarkers Predicting Small-for-Gestational-Age Neonates. Biological Research for Nursing, 20(Issue 3). doi:10.1177/1099800418760997
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  Background: Neonates born small for gestational age (SGA) face increased risk of neonatal mortality, childhood developmental problems, and adult disease. The placenta is a key factor in SGA development because of its multiple biological processes that underlie fetal growth. However, valid and reliable placental biomarkers of SGA have not been determined. Objectives: The objective of this article was to systematically identify and review studies examining associations between placental biomarkers and SGA and assess those biomarkers’ predictive value. Methods: Use of the matrix method and the PRISMA guidelines ensured systematic identification of relevant articles based on selection criteria. PubMed, CINAHL, and EMBASE were searched for English articles published in 2005–2016 that addressed relationships between placental biomarkers and SGA. Results: The search captured 466 articles; 13 met selection criteria. The review identified 14 potential placental biomarkers for SGA, with placental growth factor and soluble fms-like tyrosine kinase 1 being the most commonly studied. However, findings for these and other biomarkers have often been contradictory. Thus, no placental biomarkers have been confirmed as reliable for predicting SGA. Conclusion: The inconsistent findings suggest low placental biomarker reliability, perhaps due to the multifactorial nature of SGA. This review is novel in its focus on identifying potential placental biomarkers for SGA, producing a better understanding of how placental function underlies fetal growth. Nevertheless, use of placental biomarkers alone may not be adequate for predicting SGA. Therefore, combinations of biomarkers and other predictive tests should be evaluated for their ability to predict risk of SGA.
• Maeder, A. B., Vonderheid, S. C., Park, C. G., Bell, A. F., McFarlin, B. L., Vincent, C., & Carter, C. S. (2017). Titration of Intravenous Oxytocin Infusion for Postdates Induction of Labor Across Body Mass Index Groups. JOGNN - Journal of Obstetric, Gynecologic, and Neonatal Nursing, 46(Issue 4). doi:10.1016/j.jogn.2017.02.006
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  Objective To evaluate whether oxytocin titration for postdates labor induction differs among women who are normal weight, overweight, and obese and whether length of labor and birth method differ by oxytocin titration and body mass index (BMI). Design Retrospective cohort study. Setting U.S. university-affiliated hospital. Participants Of 280 eligible women, 21 were normal weight, 134 were overweight, and 125 were obese at labor admission. Methods Data on women who received oxytocin for postdates induction between January 1, 2013 and June 30, 2013 were extracted from medical records. Oxytocin administration and labor outcomes were compared across BMI groups, controlling for potential confounders. Data were analyzed using χ2, analysis of variance, analysis of covariance, and multiple linear and logistic regression models. Results Women who were obese received more oxytocin than women who were overweight in the unadjusted analysis of variance (7.50 units compared with 5.92 units, p =.031). Women who were overweight had more minutes between rate changes from initiation to maximum than women who were obese (98.19 minutes compared with 83.39 minutes, p =.038). Length of labor increased with BMI (p =.018), with a mean length of labor for the normal weight group of 13.96 hours (standard deviation = 8.10); for the overweight group, 16.00 hours (standard deviation = 7.54); and for the obese group, 18.30 hours (standard deviation = 8.65). Cesarean rate increased with BMI (p =.001), with 4.8% of normal weight, 33.6% of overweight, and 42.4% of obese women having cesarean births. Conclusion Women who were obese and experienced postdates labor induction received more oxytocin than women who were non-obese and had longer length of labor and greater cesarean rates.
• Bell, A. F., Carter, C. S., Davis, J. M., Golding, J., Adejumo, O., Pyra, M., Connelly, J. J., & Rubin, L. H. (2016). Childbirth and symptoms of postpartum depression and anxiety: a prospective birth cohort study. Archives of Women's Mental Health, 19(Issue 2). doi:10.1007/s00737-015-0555-7
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  We investigated associations between aspects of childbirth and elevated postpartum symptoms of depression and anxiety. We employed secondary analysis of perinatal data (N = 4657–4946) from the Avon Longitudinal Study of Parents and Children (ALSPAC) birth cohort. Multivariable logistic regression models (adjusted for covariates) examined predictors of elevated symptoms of postpartum depression and anxiety. Predictors included the following: type of delivery (normal physiological vs. interventive non-physiological), immediate postpartum complications, and maternal perception of the recent birth experience. The Edinburgh Postnatal Depression Scale assessed elevated symptoms of depression (score ≥ 13), and the Crown-Crisp Experiential Index assessed elevated symptoms of anxiety (score ≥ 9) at 2 and 8 months after delivery. A more negative perception of the recent birth experience was associated with elevated symptoms of anxiety at 2 months [odds ratio (OR) 1.52, 95 % confidence interval (CI) 1.25–1.85] and 8 months (OR 1.30, 95 % CI 1.06–1.60) postpartum but was not associated with elevated symptoms of depression at either time point. Type of delivery (physiological vs. non-physiological) and immediate postpartum complications were not associated with elevated symptoms of depression or anxiety. Our findings suggest that improving women’s childbirth experience may decrease the likelihood of postpartum anxiety, but not postpartum depression.
• Bell, A. F., Carter, C. S., Steer, C. D., Golding, J., Davis, J. M., Steffen, A. D., Rubin, L. H., Lillard, T. S., Gregory, S. P., Harris, J. C., & Connelly, J. J. (2015). Interaction between oxytocin receptor DNA methylation and genotype is associated with risk of postpartum depression in women without depression in pregnancy. Frontiers in Genetics, 6(Issue). doi:10.3389/fgene.2015.00243
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  Postpartum depression (PPD) affects up to 19% of women, negatively impacting maternal and infant health. Reductions in plasma oxytocin levels have been associated with PPD and heritability studies have established a genetic contribution. Epigenetic regulation of the oxytocin receptor gene (OXTR) has been demonstrated and we hypothesized that individual epigenetic variability at OXTR may impact the development of PPD and that such variability may be central to predicting risk. This case-control study is nested within the Avon Longitudinal Study of Parents and Children and included 269 cases with PPD and 276 controls matched on age group, parity, and presence or absence of depressive symptoms in pregnancy as assessed by the Edinburgh Postnatal Depression Scale. OXTR DNA methylation (CpG site -934) and genotype (rs53576 and rs2254298) were assayed from DNA extracted from blood collected during pregnancy. Conditional logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association of elevated symptoms of PPD with genotype, methylation, and their interaction adjusted for psychosocial factors (n = 500). There was evidence of an interaction between rs53576 and methylation in the OXTR gene amongst women who did not have depression prenatally but developed PPD (p interaction = 0.026, adjusted for covariates, n = 257). Those women with GG genotype showed 2.63 greater odds of PPD for every 10% increase in methylation level (95% CI: 1.37, 5.03), whereas methylation was unrelated to PPD amongst "A" carriers (OR = 1.00, 95% CI: 0.58, 1.73). There was no such interaction among women with PPD and prenatal depression. These data indicate that epigenetic variation that decreases expression of OXTR in a susceptible genotype may play a contributory role in the etiology of PPD.
• Bell, A. F., Erickson, E. N., & Carter, C. S. (2014). Beyond labor: The role of natural and synthetic oxytocin in the transition to motherhood. Journal of Midwifery and Women's Health, 59(Issue 1). doi:10.1111/jmwh.12101
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  Emerging research raises questions that synthetic oxytocin during childbirth may alter the endogenous oxytocin system and influence maternal stress, mood, and behavior. Endogenous oxytocin is a key component in the transition to motherhood, affecting molecular pathways that buffer stress reactivity, support positive mood, and regulate healthy mothering behaviors (including lactation). Synthetic oxytocin is widely used throughout labor and postpartum care in modern birth. Yet research on the implications beyond labor of maternal exposure to perinatal synthetic oxytocin is rare. In this article, we review oxytocin-related biologic pathways and behaviors associated with the transition to motherhood and evidence supporting the need for further research on potential effects of intrapartum oxytocin beyond labor. We include a primer on oxytocin at the molecular level. © 2014 by the American College of Nurse-Midwives.
• Bell, A. F., White-Traut, R., & Rankin, K. (2013). Fetal exposure to synthetic oxytocin and the relationship with prefeeding cues within one hour postbirth. Early Human Development, 89(Issue 3). doi:10.1016/j.earlhumdev.2012.09.017
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  Background: Prefeeding cues are oral-motor neurobehaviors that communicate feeding readiness, and the ability to self-comfort and regulate behavioral state. Intrapartum and newborn procedures have been associated with altered frequency and emergence of prefeeding cues soon after birth. Intrapartum synthetic oxytocin is commonly used for labor induction/augmentation in the US, yet there is little research on potential effects on infant neurobehavioral cues. Aims: To explore whether fetal exposure to synthetic oxytocin was associated with the infant's level of prefeeding organization shortly after birth. Study design: Cohort. Subjects: A convenience sample of 47 healthy full-term infants (36 exposed and 11 unexposed to intrapartum synthetic oxytocin) was studied. Exclusion criteria: Fetal distress, vacuum/forceps, cesarean, and low Apgar. Outcome measures: Videotapes of infants (45-50. min postbirth) were coded for frequency of eight prefeeding cues, and analyzed by level of prefeeding organization. Results: In general, fewer prefeeding cues were observed in infants exposed versus unexposed to synOT and differences were significant for brief and sustained hand to mouth cues [incidence rate ratio (95% CI). =. 0.6 (0.4, 0.9) and 0.5 (0.2, 0.9), respectively]. Forty-four percent of exposed infants demonstrated a low level of prefeeding organization, compared to 0% from the unexposed group. In contrast, 25% of exposed versus 64% of unexposed infants demonstrated high prefeeding organization. After adjusting for covariates, exposed infants were at 11.5 times (95% CI. =. 1.8-73.3) the odds of demonstrating low/medium versus high levels of prefeeding organization compared to unexposed infants. Conclusions: Newborn neurobehavioral cues may be sensitive to intrapartum synthetic oxytocin. © 2012 Elsevier Ltd.
• Dahlen, H. G., Kennedy, H. P., Anderson, C. M., Bell, A. F., Clark, A., Foureur, M., Ohm, J. E., Shearman, A. M., Taylor, J. Y., Wright, M. L., & Downe, S. (2013). The EPIIC hypothesis: Intrapartum effects on the neonatal epigenome and consequent health outcomes. Medical Hypotheses, 80(Issue 5). doi:10.1016/j.mehy.2013.01.017
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  There are many published studies about the epigenetic effects of the prenatal and infant periods on health outcomes. However, there is very little knowledge regarding the effects of the intrapartum period (labor and birth) on health and epigenetic remodeling. Although the intrapartum period is relatively short compared to the complete perinatal period, there is emerging evidence that this time frame may be a critical formative phase for the human genome. Given the debates from the National Institutes of Health and World Health Organization regarding routine childbirth procedures, it is essential to establish the state of the science concerning normal intrapartum epigenetic physiology. EPIIC (Epigenetic Impact of Childbirth) is an international, interdisciplinary research collaboration with expertise in the fields of genetics, physiology, developmental biology, epidemiology, medicine, midwifery, and nursing. We hypothesize that events during the intrapartum period - specifically the use of synthetic oxytocin, antibiotics, and cesarean section - affect the epigenetic remodeling processes and subsequent health of the mother and offspring. The rationale for this hypothesis is based on recent evidence and current best practice. © 2013 Elsevier Ltd.
• Bell, A. F., White-Traut, R., Wang, E. C., & Schwertz, D. (2012). Maternal and Umbilical Artery Cortisol at Birth: Relationships With Epidural Analgesia and Newborn Alertness. Biological Research for Nursing, 14(Issue 3). doi:10.1177/1099800411413460
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  Background: Newborn alertness soon after birth facilitates mother-infant interaction and may be related to umbilical cortisol levels. Yet, little is known about whether epidural analgesia influences umbilical cortisol at birth. Aim: The aims of this study were to explore relationships between exposure to epidural analgesia and maternal and umbilical cortisol; maternal and umbilical cortisol levels at birth; and umbilical cortisol and infant alertness after birth. Method: Forty women were self-selected to unmedicated or epidural labors in this pilot study. Maternal saliva and infant umbilical artery (UA) plasma at birth were enzyme immunoassayed for cortisol. Infant alertness was assessed nearly 1 hr after birth. Results: Maternal cortisol was higher in the unmedicated versus epidural group (p = .003). Umbilical cortisol was not related to epidural analgesia exposure but was related to duration of labor (higher cortisol with longer labors; p = .026). Maternal cortisol level explained 55% of the variance in umbilical cortisol in the unmedicated group (p = .002), but there was no significant shared variance in the epidural sample (p = .776). There was a positive correlation (r2 = .17, p = .008) between umbilical cortisol and infant alertness. Latina infants demonstrated a higher frequency of alertness than Black infants. In multivariate analysis, umbilical cortisol (p = .049) and race/ethnicity (p = .024) remained significant predictors of infant alertness. Conclusions: Our findings indicate that higher umbilical cortisol is related to greater infant alertness soon after birth. While epidural analgesia did not directly relate to infant cortisol, other factors contributed to higher umbilical cortisol. © The Author(s) 2012.
• Bell, A., White-Traut, R., & Medoff-Cooper, B. (2011). On "Neonatal Neurobehavioral Organization after Exposure to Maternal Epidural Analgesia in Labor". JOGNN - Journal of Obstetric, Gynecologic, and Neonatal Nursing, 40(Issue 2). doi:10.1111/j.1552-6909.2011.01222_1.x
• Bell, A. F., White-Traut, R., & Medoff-Cooper, B. (2010). Neonatal neurobehavioral organization after exposure to maternal epidural analgesia in labor. JOGNN - Journal of Obstetric, Gynecologic, and Neonatal Nursing, 39(Issue 2). doi:10.1111/j.1552-6909.2010.01100.x
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  Objective:: To explore relationships between maternal epidural analgesia and two measures of neurobehavioral organization in infants at the initial feeding 1 hour after birth. Design:: Prospective comparative design. Setting:: Inner-city community hospital, Chicago, Illinois. Participants:: Convenience sample of 52 low-risk, mainly Black and Latino, mother/infant dyads. Methods:: Mothers self-selected to labor with epidural or no labor pain medication. Neonatal neurobehavioral organization was measured in term infants at the initial feeding 1 hour after birth. A nutritive sucking apparatus generated data on total number of sucks and sucking pressure. Video recordings of infants (before and after the initial feeding) were coded for behavioral states, with analysis on frequency of alertness. Results:: Total number of sucks and sucking pressure were not related to epidural exposure, although an epidural drug dosage effect on total number of sucks was evident when gender was a factor. Unmedicated girls demonstrated more sucks than girls in the high-dosage epidural group (p=.027). Overall, girls exhibited stronger sucking pressure than boys (p=.042). Frequency of alertness was not related to epidural exposure, although longer labor was related to greater alertness (p=.003), and Latino infants were more alert than Black infants (p=.002). Conclusions:: Results suggest attenuated neonatal nutritive sucking organization in girls after exposure to high maternal epidural dosages. In comparison to boys, girls may have enhanced neurobehavioral organization at birth. Race/ethnicity and alertness may have spurious associations in which hidden factors drive the relationship. © 2010 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses.
• White-Traut, R., Watanabe, K., Pournajafi-Nazarloo, H., Schwertz, D., Bell, A., & Carter, C. S. (2009). Detection of salivary oxytocin levels in lactating women. Developmental Psychobiology, 51(Issue 4). doi:10.1002/dev.20376
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  Oxytocin is a neuropeptide with widespread influence on many physiological and social functions including: labor and birth, lactation, sexual behavior, nurturing maternal behaviors, and stress reduction. However, our understanding of oxytocin's roles has been hampered by lack of noninvasive methods for assessing oxytocin levels. The goal of the present study was to assess whether oxytocin could be detected in saliva and whether changes occurred in the pattern of oxytocin release among lactating women from before, at initiaton and after breast feeding. Using a prospective repeated measures design, 11 research participants each provided 18 saliva samples during three feeding cycles (before, at initiation and after breast feeding) for two 24-hr data collection periods (Days 1 and 2). Within each day, saliva was collected at late evening, early morning, and late morning. Salivary samples were concentrated fourfold by dehydration prior to analysis and oxytocin was measured in saliva using an enzyme immunoassay (EIA). Salivary oxytocin values, when reconverted to their original levels, ranged from 6.44 to 61.05 pg/ml. Oxytocin values in saliva varied significantly as a function of the breast feeding cycle, but did not show reliable differences as a function of the time of feeding. Oxytocin was highest before feeding, followed by a decrease at initiation of feeding, and an increase at 30 min after feeding. The findings suggest that oxytocin release into saliva increases in anticipation of feedings. This study also supports the potential usefulness of salivary measures of oxytocin as a noninvasive index of changes in this peptide. © 2009 Wiley Periodicals, Inc.
• Bell, A. F., Lucas, R., & White-Traut, R. C. (2008). Concept clarification of neonatal neurobehavioural organization. Journal of Advanced Nursing, 61(Issue 5). doi:10.1111/j.1365-2648.2007.04561.x
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  Title. Concept clarification of neonatal neurobehavioural organization Aim. This paper is a report of a concept analysis of neonatal neurobehavioural organization for healthy full-term infants. Background. The neonatal period is an opportune time for researchers and clinicians to assess and intervene for optimal neurobehavioural organization. Yet there is inconsistency and lack of clarity in a scientifically grounded definition of neonatal neurobehavioural organization. Clarification of the concept will strengthen research findings that influence practice for optimal infant development. Method. A concept analysis of the literature between 1939 and 2007 (n = 57) was conducted using Penrod and Hupcey's principle-based concept analysis and Morse's concept clarification. Findings. The concept analysis within and across multiple disciplines revealed: (1) a view of the concept as a holistic phenomenon with multiple dimensions; (2) no agreement on the ideal instrument to operationally define the concept; and (3) consistency in implied meaning, but great variability in terminology. Neonatal neurobehavioural organization was defined as the ability of the neonate to use goal-directed states of consciousness, in reciprocal interaction with the caregiving environment, to facilitate the emergence of differentiating, hierarchical, and coordinated neurobehavioural systems, with ever-increasing resiliency and capacity to learn from complex stimuli. Conclusion. A clear conceptual definition will help the international community to communicate effectively within and between disciplines and to apply evidence-based research findings. It will encourage the development of valid and reliable instruments to capture the concept's multiple dimensions and direct attention to the infant's experience, which sculpts early neurobehavioural organization. © 2007 Blackwell Publishing Ltd.
• Bell, A. (2007). Don't we want aroused and alert babies at birth? [10]. BJOG: An International Journal of Obstetrics and Gynaecology, 114(Issue 1). doi:10.1111/j.1471-0528.2006.01157.x
• Bell, A. F. (2007). Nurse-Midwife and scientist: Stuck in the middle?. JOGNN - Journal of Obstetric, Gynecologic, and Neonatal Nursing, 36(Issue 1). doi:10.1111/j.1552-6909.2006.00111.x
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  The nurse-midwife and scientist share similar ethos (fundamental attitudes that guide action); yet, in their respective professional roles, ethos can translate into actions that appear discordant. Discord can lead to resolution, when examined through the primary principles of ethical conduct: autonomy, beneficence, nonmalfeasance, and justice. © 2007 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses.
• Bell, A., & McFarlin, B. L. (2006). Maternal and Fetal Stress Responses During Birth: Adaptive or Maladaptive?. Journal of Midwifery and Women's Health, 51(Issue 5). doi:10.1016/j.jmwh.2006.06.005

Presentations

• Bell, A. (2024, January). Utitled. Building From Within Conference. University of Arizona, Tucson: Scientific Hub for Empowering Research on female health Advancement (SHERA) Initiative.
• Bell, A. (2024, May). Lessons learned from my first NIH funded R01. Midwifery Research & Quality Exchange. virtual podium: American College of Nurse-Midwives Division of Research.
• White-Traut, R., Feldman, R., MacLean, E., Tecot, S. R., Carter, C. S., Bedrick, E. J., Bell, A., White-Traut, R., Feldman, R., MacLean, E., Tecot, S. R., Carter, C. S., Bedrick, E. J., & Bell, A. (2024, May). An NIH-funded R01 RCT with mother-infant dyads, birth data and repeated perinatal biobehavioral measures. Midwifery Research & Quality Exchange, American College of Nurse-Midwives Division of Research. Virtual: American College of Nurse-Midwives.

Poster Presentations

• Bell, A., Bedrick, E., Carter, C. S., Feldman, R., MacLean, E., Tecot, S., & White-Traut, R. (2024, May). An NIH-funded R01 RCT With Mother-Infant Dyads, Birth Data and Repeated Perinatal Biobehavioral Measures. Midwifery Research & Quality Exchange. Virtual: American College of Nurse-Midwives Division of Research.
• Boyles, S., & Bell, A. (2024, April). Parenting Stress and a Multisensory Infant Massage: A Secondary Analysis.. Western Institute of Nursing’s 57th Annual Nursing Research Conference. Salt Lake City, UT: Western Institute of Nursing.