The epidemiology of syphilis in pregnancy.

This study evaluated the magnitude, risk factors and outcomes of syphilis in pregnancy in a large cohort of women in four countries participating in the World Health Organization (WHO) antenatal care trial. All women attending the first prenatal care at each selected clinic were enrolled. Screening at the first antenatal visit was routinely performed with either rapid plasma reagin or Venereal Disease Research Laboratory and confirmed by fluorescent treponemal antibody absorption. All women also had the same syphilis tests after delivery. The initial prevalence, the incidence during pregnancy and the overall prevalence of syphilis at delivery were 0.9%, 0.4% and 1.3% respectively. Risk factors for syphilis during pregnancy were younger age for the incidence and older age and a history of stillbirth for the prevalence. Women with syphilis during pregnancy had significantly more adverse outcomes. We support the recommendation that in addition to the initial testing, a second routine test for syphilis ought to be established early in the third trimester even in low prevalence areas.

WHO antenatal care randomised trial for the evaluation of a new model of routine antenatal care.

BACKGROUND: We undertook a multicentre randomised controlled trial that compared the standard model of antenatal care with a new model that emphasises actions known to be effective in improving maternal or neonatal outcomes and has fewer clinic visits. METHODS: Clinics in Argentina, Cuba, Saudi Arabia, and Thailand were randomly allocated to provide either the new model (27 clinics) or the standard model currently in use (26 clinics). All women presenting for antenatal care at these clinics over an average of 18 months were enrolled. Women enrolled in clinics offering the new model were classified on the basis of history of obstetric and clinical conditions. Those who did not require further specific assessment or treatment were offered the basic component of the new model, and those deemed at higher risk received the usual care for their conditions; however, all were included in the new-model group for the analyses, which were by intention to treat. The primary outcomes were low birthweight (<2500 g), pre-eclampsia/eclampsia, severe postpartum anaemia (<90 g/L haemoglobin), and treated urinary-tract infection. There was an assessment of quality of care and an economic evaluation. FINDINGS: Women attending clinics assigned the new model (n=12568) had a median of five visits compared with eight within the standard model (n=11958). More women in the new model than in the standard model were referred to higher levels of care (13.4% vs 7.3%), but rates of hospital admission, diagnosis, and length of stay were similar. The groups had similar rates of low birthweight (new model 7.68% vs standard model 7.14%; stratified rate difference 0.96 [95% CI -0.01 to 1.92]), postpartum anaemia (7.59% vs 8.67%; 0.32), and urinary-tract infection (5.95% vs 7.41%; -0.42 [-1.65 to 0.80]). For pre-eclampsia/eclampsia the rate was slightly higher in the new model (1.69% vs 1.38%; 0.21 [-0.25 to 0.67]). Adjustment by several confounding variables did not modify this pattern. There were negligible differences between groups for several secondary outcomes. Women and providers in both groups were, in general, satisfied with the care received, although some women assigned the new model expressed concern about the timing of visits. There was no cost increase, and in some settings the new model decreased cost. INTERPRETATIONS: Provision of routine antenatal care by the new model seems not to affect maternal and perinatal outcomes. It could be implemented without major resistance from women and providers and may reduce cost.

Methodological considerations on the design and analysis of an equivalence stratified cluster randomization trial.

The World Health Organization and collaborating institutions in four developing countries have conducted a multi-centre randomized controlled trial, in which clinics were allocated at random to two antenatal care (ANC) models. These were the standard 'Western' ANC model and a 'new' ANC model consisting of tests, clinical procedures and follow-up actions scientifically demonstrated to be effective in improving maternal and newborn outcomes. The two models were compared using the equivalence approach. This paper discusses the implications of the equivalence approach in the sample size calculation, analysis and interpretation of results of this cluster randomized trial. It reviews the ethical aspects regarding informed consent, concluding that the Zelen design has a place in cluster randomization trials. It describes the estimation of the intracluster correlation coefficient (ICC) in a stratified cluster randomized trial using two methods and reports estimates of the ICC obtained for many maternal, newborn and perinatal outcomes. Finally, it discusses analytical problems that arose: issues encountered using a composite index, heterogeneity of the intervention effect across sites, the choice of the method of analysis and the importance of efficacy analyses. The choice of the clustered Woolf estimator and the generalized estimating equations (GEE) as the methods of analysis applied is discussed.

Risk factors for stunting and wasting at age six, twelve and twenty-four months for squatter children of Karachi, Pakistan.

OBJECTIVE: A high proportion of stunting and wasting in children under-five has been reported from developing countries. This paper presents the nutritional status of a two year cohort of urban squatter children in Karachi, Pakistan and assesses risk factors for wasting and stunting at the reference ages of six, twelve and twenty-four months. METHODS: A birth cohort of 738 children were visited at specific intervals by trained nurses to collect information on anthropometric measurements, feeding practices and intercurrent illnesses. Socioeconomic and demographic information included water and sanitation facilities, availability of electricity, type of house construction material and average monthly income. Information about the mother's reproductive history was also obtained. RESULTS: At two years the proportion of stunting and wasting was 41.8% and 10.6% respectively. Intrauterine growth retarded children had a higher risk of stunting and wasting at all reference ages as compared to children who were appropriate for gestational age. In the logistic regression models, intrauterine growth retardation was the only significant risk factor that remained in all models at each reference age. CONCLUSION: The consistent association of IUGR for stunting and wasting adds to the growing body of evidence that by improving maternal health we will ultimately break the vicious cycle of malnourishment and improve the health and well-being of future generations. We suggest interventions to improve the nutritional status of Pakistani urban children living in squatter settlements focused on mothers and children.

The role of son preference in reproductive behaviour in Pakistan.

The sex of surviving children is an important determinant of reproductive behaviour in South Asia in general and Pakistan in particular. This cohort study evaluates the role of the sex of children on reproductive intentions and subsequent behaviour of women in urban slums of Karachi, Pakistan. The analysis is based on two rounds of surveys conducted in 1990-91 and 1995 of a cohort of married women aged 15-49 years. The results show that pregnancies became increasingly unwanted as the number of surviving sons increased. The sex of surviving children was strongly correlated with subsequent fertility and contraceptive behaviour. However, rather than an exclusive son preference, couples strove for one or more sons and at least one surviving daughter. The policy implications of the link between overt son preference and low status of women are discussed.

Deaths attributable to injuries in infants, United States, 1983-1991.

OBJECTIVE: To describe risk factors for injury death among infants in the United States by the specific external cause of death. METHODS: Data were analyzed from the US-linked birth/infant death files for the years 1983-1991. Potential risk factors for injury death were identified from birth certificate data and included both maternal and infant factors. Injury rates were calculated by external cause of death. Characteristics of infants who died from an injury were compared with those of the entire birth cohort. The independent effect of potential risk factors was assessed in multivariate analyses using a case-control study design. RESULTS: A total of 10 370 injury deaths were identified over the 9-year study period (29. 72/100 000 live births). The leading causes of death were homicide, suffocation, motor vehicle crashes, and choking (inhalation of food or objects). There was no significant temporal trend in the overall rate of injury death; however, this was because significant increases in the rates of death from homicide (6.4%/year) and mechanical suffocation (3.7%/year) were offset by decreases in rates of death from fires (-4.7%/year) and choking (-4.6%/year). In adjusted analyses, infants born to mothers with no prenatal care, <12 years of education, two or more previous live births, Native American race, or <20 years of age were at twice the risk of injury death compared with the lowest risk groups (initiation of prenatal care in the first trimester, >/=16 years of education, no previous live births, white, or >/=25 years of age). When analyzed by the specific cause of death, the factors that were associated most strongly with death varied. For example, Native Americans were at greatest risk of a motor vehicle related death (compared with whites: OR: 3.6; 95% CI: 1.8-7.1), and infants with birth weights of <1500 g were at greatest risk of death attributable to inhalation of food (compared with >/=2500 g: OR: 9.6; 95% CI: 3.3-28.0) or objects (OR: 11.8; 95% CI: 4.5-30.5). CONCLUSION: A number of sociodemographic characteristics are associated with an increased risk of injury-related death in infants. The strength of associations between specific risk factors and death varies with the external cause of death, thus identifying high-risk subgroups for targeting of cause-specific interventions and simultaneously increasing our understanding of the individual and societal mechanisms underlying these tragedies.

Serial levels of serum organochlorines during pregnancy and postpartum.

In utero exposure to dichlorodiphenyldichloroethene and polychlorinated biphenyls, within the range found in the general U.S. population, may produce detectable effects in offspring. To design studies of the effects of in utero organochlorine exposure, we obtained data on the relationship between gestational and perinatal maternal levels in females on several occasions. We studied 67 pregnant women in the United States who agreed to have their blood drawn once during each trimester and once postpartum. We examined the Pearson correlation coefficient between the natural logarithm of levels (microg/g serum lipid). The correlation, r, among levels in the first and third trimester was .86 and .77 for dichlorodiphenyldichloroethene and for polychlorinated biphenyls. Correlations among levels determined at other times (i.e., second trimester and postpartum) were similar. On the basis of these results, we suggest that in studies of the effects of in utero or perinatal exposure to the aforementioned compounds, the time when specimens are collected is not critical.

Infant injury deaths with unknown intent: what else do we know?

OBJECTIVES: Strong evidence based on case record reviews indicates that the incidence of child homicide reported from death certificates is under ascertained. The characteristics of infant injury fatalities with undetermined, but suspicious, intent were compared for the probability that they should be considered homicides. METHODS: Using linked birth and death certificates for all birth cohorts in the US from 1983-91, 2345 injury fatalities reported as intentional, 7594 as unintentional, and 431 as undetermined intent were identified. Maternal and infant variables potentially predictive of injury fatalities were selected based on increased bivariate associations. Relative risks of injury death by intentional, unintentional, and undetermined intent were assessed for maternal and infant characteristics. RESULTS: Relative risks were consistently higher across all intent categories for infants of mothers with the least education, no prenatal care, young maternal age, and single marital status, as well as for infants who are second or later born, preterm, black, or American Indian. Fatalities with undetermined intent have larger relative risks in the highest risk categories than either intentional or unintentional injuries. Deaths with undetermined intent have risk profiles that more closely resemble profiles for intentional deaths than unintentional. CONCLUSIONS: Injury homicide rates would be almost 20% greater than official classifications indicate if deaths with undetermined intent were included. In analyses of infant homicide, excluding deaths of undetermined intent may lead to an underestimation of the magnitude of the public health problem of intentional injuries among infants. Other studies based on record reviews from multiple sources indicate that misclassification and under ascertainment of homicides may be even greater.

Role of intrauterine growth retardation on physical growth of Pakistani squatter children from birth to 2 years of age.

A birth cohort of 727 squatter children from Karachi was followed to study growth patterns by measuring anthropometric parameters at specific ages during the first 2 years of life. The mean weight and length of the intrauterine growth retarded and appropriate for gestational age children fell below the 10th percentile of the NCHS standards after 9 months and further deteriorated in the subsequent study period. However, the intrauterine growth retarded children showed slightly higher growth velocities compared to appropriate for gestational age children in the first few months for all four measurements, but subsequently these differences in growth velocities diminished. Our results suggest that nutrition intervention strategies should begin in early pregnancy.

The WHO antenatal care randomised controlled trial: rationale and study design.

The World Health Organisation and collaborating institutions in developing countries are conducting a multicentre randomised controlled trial to evaluate a new antenatal care (ANC) programme, consisting of tests, clinical procedures and follow-up actions scientifically demonstrated to be effective in improving maternal and newborn outcomes. These activities are distributed, for practical reasons, over four visits during the course of pregnancy and are aimed at achieving predetermined goals. The study is taking place in four countries, Argentina, Cuba, Saudi Arabia and Thailand. Recruitment of study subjects started on 1 May 1996. All 53 ANC clinical units had been enrolled by December 1996. Clinics in each country were randomly allocated (cluster randomisation) to provide either the new programme or the traditional programme currently in use. Approximately 24,000 women presenting for ANC at these clinics over an average period of 18 months will have been recruited. As women attending the control clinics receive the 'best standard treatment' as currently offered in these clinics, individual informed consent is requested only from women attending the intervention clinics. Authorities of the corresponding health districts and all participating clinics have provided written institutional informed consent before randomisation. The primary outcome of the trial in relation to maternal conditions is the rate of a morbidity indicator index, defined as the presence of at least one of the following conditions for which ANC is relevant: (a) pre-eclampsia or eclampsia during pregnancy or within 24 h of delivery; (b) postpartum anaemia (haemoglobin < 90 g/L); or (c) severe urinary tract infection/pyelonephritis, defined as an episode requiring antibiotic treatment and/or hospitalisation. The primary fetal outcome is the rate of low birthweight (< 2500 g). Adverse maternal and fetal outcomes are expected for approximately 10% of the control group. Several maternal and perinatal secondary outcomes are also considered. A comprehensive cost-effectiveness analysis and women's and providers' satisfaction evaluation are performed concurrently with the trial. Health-care programmes should be rigorously evaluated by randomised controlled trials, which are feasible in developing countries and should be conducted before introducing new treatments or health interventions.

PIP: The procedures and examinations included in currently practiced prenatal care have not been subjected to systematic, scientifically rigorous evaluation. The World Health Organization (WHO) Antenatal Care Randomized Controlled Trial is evaluating a new prenatal care regimen with demonstrated efficacy in improving maternal and newborn outcomes. Program activities include screening for health conditions that increase the risk of specific adverse pregnancy outcomes, therapeutic interventions known to affect these outcomes beneficially, and education of pregnant women regarding potential health emergencies and appropriate responses. The study's hypothesis is that the tests, clinical procedures, and follow-up actions associated with this approach, delivered over the course of four visits during pregnancy, are more effective than the traditional prenatal care package in terms of specific maternal and perinatal results without being more expensive. This paper addresses the rationale, design, and methodology of this trial. 53 prenatal care clinics in four well-defined geographic areas (Khon Kaen Province, Thailand; Havana, Cuba; Rosario, Argentina; and Jeddah, Saudi Arabia) have been randomized to the two arms of the study. By the end of 1997, 24,000 women presenting for prenatal care at these sites had been enrolled. The primary maternal outcome is the morbidity indicator index, defined as the presence of at least one of the following conditions: pre-eclampsia or eclampsia during pregnancy or within 24 hours of delivery, postpartum anemia, or severe urinary tract infection/pyelonephritis. The primary fetal outcome is the rate of low birth weight. A comprehensive cost-effectiveness analysis and provider satisfaction evaluation will be performed concurrently with the trial. Data collection will be completed in 1998.

Methodological considerations in the design of the WHO Antenatal Care Randomised Controlled Trial.

We discuss methodological issues arising in a recent evaluation trial of a new antenatal care programme, as sponsored by the Special Programme of Research, Development and Research Training in Human Reproduction, and WHO's Division of Reproductive Health (Technical Support). The randomisation unit for the trial is the antenatal care clinic, with 53 clinics located in four countries randomly allocated to provide either the new programme or the traditional programme currently in use. Approximately 24,000 women presenting for antenatal care over an average period of 18 months will have been recruited.

PIP: The World Health Organization (WHO) Antenatal Care Randomized Controlled Trial is evaluating the impact of a new program of prenatal care on the health of mothers and newborns. Study subjects will receive either the standard prenatal care program currently offered at participating sites or a new regimen comprised of scientifically evaluated, objective-oriented prenatal care services. A total of 24,000 pregnant women from 53 prenatal care clinics in Argentina, Cuba, Thailand, and Saudi Arabia have been enrolled and stratified on the basis of the number of pregnant women enrolled in each clinic during the year preceding the study, the type of clinic (free-standing or hospital), and the administrative health system to which they belong. This article discusses methodological issues related to the study's design, with emphasis on sample size considerations, planned approaches to the statistical analysis, and data quality control. The rationales for selecting clinics as the unit of randomization are to reduce the risk of treatment contamination, encourage participation, and facilitate administrative and logistic convenience in the implementation of the intervention. Randomization of intact clinics to different intervention groups with predefined strata reflects the fact that the aim of the trial is to show the equivalence, not necessarily the superiority, of the new prenatal care program with the existing program of standard care. The two major adverse outcomes, a high maternal morbidity index and low birth weight, are expected to be in the range of 10%. To ensure that a statistically nonsignificant effect can be interpreted meaningfully, the trial has been designed to have a 90% power for ruling out an absolute difference of at least 0.02 in the expected incidence of the primary end points. A confidence interval approach was selected for sample size estimation, as recommended for equivalence trials, to provide additional assurance that the sample size is adequate.

Risk factors for infant homicide in the United States.

BACKGROUND: Homicide is the leading cause of infant deaths due to injury. More than 80 percent of infant homicides are considered to be fatal child abuse. This study assessed the timing of deaths and risk factors for infant homicide. METHODS: Using linked birth and death certificates for all births in the U.S. between 1983 and 1991, we identified 2776 homicides occurring during the first year of life. Birth-certificate variables were reviewed in both bivariate and multivariate stratified analyses. Variables potentially predictive of homicide were selected on the basis of increased relative risks among subcategories with adequate numbers for stable estimates. RESULTS: Half the homicides occurred by the fourth month of life. The most important risk factors were a second or subsequent infant born to a mother less than 17 years old (relative risk, 10.9) or 17 to 19 years old (relative risk, 9.3), as compared with a first infant born to a mother 25 years old or older; a maternal age of less than 15 years, as compared with an age of at least 25 years (relative risk, 6.8); no prenatal care as compared with early prenatal care (relative risk, 10.4); and less than 12 years of education among mothers who were at least 17 years old (relative risk, 8.0), as compared with 16 or more years of education. CONCLUSIONS: Childbearing at an early age was strongly associated with infant homicide, particularly if the mother had given birth previously. Our findings may have implications for prevention.

Prevalence and predictors of the prone sleep position among inner-city infants.

CONTEXT: The prone sleep position is associated with an increased risk of sudden infant death syndrome (SIDS), but few studies have assessed factors associated with the choice of infant sleep position. OBJECTIVES: To describe infant sleep position in a cohort of infants born to predominantly low-income, inner-city mothers and to identify predictors of the prone sleep position in this population. DESIGN: Prospective birth cohort study. PATIENTS AND SETTING: Three hundred ninety-four mother-infant dyads, systematically selected from 3 District of Columbia hospitals between August 1995 and September 1996. Mothers were interviewed shortly after delivery and again at 3 to 7 months postpartum. MAIN OUTCOME MEASURES: Position in which infants were placed for sleep on the night prior to the 3- to 7-month interview. RESULTS: At 3 to 7 months of age, 157 infants (40%) were placed for sleep in the prone position. Independent predictors of prone sleep position included poverty (odds ratio [OR], 1.81; 95% confidence interval [CI], 1.10-2.99), black race (OR, 2.06; 95% CI, 1.05-4.04), presence of infant's grandmother in the home (OR, 1.83; 95% CI, 1.11-3.00), and intent, as measured shortly after delivery, to place the infant in the prone position (OR, 2.28; 95% CI, 1.44-3.60). Importantly, of the 43 mothers who observed their infants in the prone sleep position while in the hospital, 40 (93%) intended to place their infants prone at home. CONCLUSIONS: A substantial proportion of infants in this predominantly low-income population were placed in the prone sleep position. Educational efforts should address both initial intentions and reinforcement of the correct sleep position, once initiated. Hospitals should ensure that healthy newborn infants are placed in the supine sleep position during the postpartum hospital stay.

Contextual determinants of maternal mortality in rural Pakistan.

Maternal mortality is high in Pakistan, particularly in the rural areas which have poor access to health services. We investigated the risk factors associated with maternal mortality in sixteen rural districts of Balochistan and the North-West Frontier (NWFP) provinces of Pakistan. We designed a nested case-control study comprising 261 cases (maternal deaths reported during last five years) and 9135 controls (women who survived a pregnancy during last five years). Using contextual analysis, we estimated the interactions between the biological risk factors of maternal mortality and the district-level indicators of health services. Women under 19 or over 39 yr of age, those having their first birth, and those having a previous history of fetal loss were at greater risk of maternal death. Staffing patterns of peripheral health facilities in the district and accessibility of essential obstetric care (EOC) were significantly associated with maternal mortality. These indicators also modified the effects of the biological risk factors of maternal mortality. For example, nulliparous women living in the under-served districts were at greater risk than those living in the better-served districts. Our results are consistent with several studies which have pointed out the role of health services in the causation of maternal mortality. Many such studies have implicated distance to hospital (an indicator of access to EOC) and lack of prenatal care as major determinants of maternal mortality. We conclude that better staffing of peripheral health facilities and improved access to EOC could reduce the risk of maternal mortality among women in rural Balochistan and the NWFP.

Does breast-feeding influence intelligence quotients at 9 and 10 years of age?

The effect of breast-feeding on intellectual development remains controversial. We explored this relationship in a high socioeconomic population in which breast-feeding was supplemented with soy containing formulas at some time during the first year of life. As part of the 1988 National Institute of Child Health and Human Development school-based survey of two metropolitan Washington, D.C. counties to identify children in the 1978 to 1979 birth cohort who had been exposed to the chloride deficient formulas Neo-Mull-Soy and Cho-Free during infancy, information on breast-feeding was also obtained on children exposed to the chloride-deficient formulas and a group of control children exposed to other soy formulas. Because no differences in intellectual development were observed between the two groups, they were combined and the effect of breast-feeding on intellectual development at 9 and 10 years was assessed. There were 176 infants that received no breast-feeding and 342 who were breast-fed. The median duration of breast-feeding was 124 days (interquartile range, 42-248 days). There were no differences in birth weight, gender or race between the infants who were breast-fed and those who were not. The mean Weschler Intelligence Scale-Revised Full Scale IQ was 122 among those breast-fed compared to 118 among those that were not (P = 0.0008). However, following adjustment by linear regression for maternal education, paternal education and annual income the adjusted mean full scale IQ was 111 among the breast-fed and 110 among the non-breast-fed (P = 0.23). Further analyses limited to those exclusively breast-fed for the first 60 days failed to demonstrate any significant relationship between breast-feeding and IQ.

Maternal mortality in different Pakistani sites: ratios, clinical causes and determinants.

BACKGROUND: Population-based estimates of maternal mortality from Pakistan are inadequate to define the magnitude of the problem or provide information on clinical causes and determinants. METHODS: Surveys were conducted in selected clusters in Karachi, Balochistan and North West Frontier Province from 1989-1992. Pre-coded questionnaires were administered to 38,563 households to ascertain household characteristics, complete pregnancy histories and deaths of household members in the five years preceding the survey. Verbal autopsy questionnaires were then conducted to establish cause of death to women in the reproductive age group. Descriptive, bivariate and multivariable analyses were carried out to determine the association between the background variables, biological and women's status indicators and maternal mortality using a nested case-control design. RESULTS: Overall, the estimated maternal mortality ratio combining the data from the different sites was 433 per 100,000 livebirths. The estimated maternal mortality ratios per 100,000 livebirths ranged from a low of 281 in Karachi to a high of 673 in Khuzdar [Balochistan]. Hemorrhage (52.9%), puerperal sepsis (16.3%) and eclampsia (14.4%) were the leading causes for direct maternal deaths. Logistic regression identified the important risk factors as poor housing construction material (OR = 2.1; 95% CI = 1.3,3.2), distance of 40 or more miles from nearest hospital (OR = 1.3; 95% CI = 0.9,1.8), grandmultigravidity (OR = 1.6; 95% CI = 1.1,2.4) and prior fetal losses (OR = 5.3; 95% CI = 3.8,7.4). CONCLUSION: Focusing on special groups of pregnant women with targeted programs such as training, monitoring and supervision of birth attendants for the provision of oxytocics, will go a long way in decreasing the proportion of maternal deaths attributed to direct, avoidable causes.

PIP: To determine the magnitude of and factors associated with maternal mortality in Pakistan, population-based surveys were conducted in selected clusters in Karachi, Balochistan, and North West Frontier Provinces during 1989-92. Questionnaires were administered to 38,563 households and verbal autopsy questionnaires were conducted when a maternal death was reported. The overall maternal mortality ratio was 433 per 100,000 live births, with a range from 281 in Karachi to 673 in Balochistan. The leading causes of death were hemorrhage (52.9%), puerperal sepsis (16.3%), and eclampsia (14.4%). Overall, the majority of maternal deaths occurred among women 20-35 years of age with 2-7 children. According to logistic regression analysis, the primary risk factors for maternal mortality were poor housing construction material (odds ratio (OR), 2.1; 95% confidence interval (CI), 1.3-3.2), distance of 40 miles or more from the nearest hospital (OR, 1.3; 95% CI, 0.9-1.8), grandmultigravidae (OR, 1.6; 95% CI, 1.1-2.4), and prior fetal losses (OR, 5.3; 95% CI, 3.8-7.4). These findings indicate a need to focus on special groups of pregnant women, especially those with a poor obstetric history and disadvantaged socioeconomic status, to decrease the high rate of maternal mortality in Pakistan.

Maternal anthropometry and infant feeding practices in Israel in relation to growth in infancy: the North African Infant Feeding Study.

Relations between maternal anthropometric status during pregnancy and infant feeding practices and growth from birth through the first 6 mo of life were examined in a cohort of 351 Israeli mother-infant pairs of North African descent. Maternal weight, height, and triceps skinfold thicknesses were determined at 6 and 9 mo of pregnancy, while infants' weights and lengths were measured at birth and at 1, 2, 3, and 6 mo of age with concurrent collection of age-specific maternal-reported infant feeding data. On the basis of multiple-linear-regression analysis that adjusted for potential covariates, mean maternal weight at the first prenatal visit and at 6 and 9 mo of pregnancy were positively associated with birth length (P for trend in all cases < 0.0001) and with linear growth between birth and 1, 3, and 6 mo of age. Maternal skinfold thickness at 9 mo of pregnancy and maternal height were also significantly associated with birth length. Moreover, maternal height, weight, and skinfold thickness at 6 and 9 mo of pregnancy were positively associated with mean birth weight. After adjustment for morbidity in the past month and other covariates, infants breast-fed exclusively had greater attained weight and weight gain in the first 3 mo compared with infants who were bottle-fed exclusively, breast-fed and bottle-fed, or solid-fed exclusively. These findings underscore the need for programs that improve the nutritional status of women before, during, and after pregnancy, and encourage exclusive breast-feeding of infants for at least the first 3 mo of life.

PIP: The associations between maternal anthropometric measures during pregnancy and infant feeding practices and growth in the first 6 months of life were investigated in a cohort of 351 mother-infant pairs of North African (Morocco, Tunisia, Algeria, or Libya) descent but currently residing in Israel's Negev region. Mean maternal weight at the first prenatal visit and at 6 and 9 months of pregnancy was significantly and positively associated with birth length and with linear growth between birth and 1, 3, and 6 months of age. Maternal skinfold thickness at 9 months of pregnancy and maternal height also were significantly associated with birth length, while maternal height, weight, and skinfold thickness at 6 and 9 months of pregnancy were positively associated with mean birth weight. The rate of exclusive breast feeding declined from 34% at 1 month to 18% at 2 months to 6% at 3 months. After adjustment for covariates such as morbidity in the preceding month, maternal anthropometric status, and socioeconomic factors, infants who were exclusively breast-fed had greater attained weight and weight gain in the first 3 months of life than their counterparts who were exclusively bottle-fed, breast- and bottle-fed, or solid-fed. These findings underscore the importance of programs that improve the nutritional status of women before, during, and after pregnancy and promote exclusive breast feeding for at least the first 3 months.