Is obesity still increasing among pregnant women? Prepregnancy obesity trends in 20 states, 2003-2009.

OBJECTIVE: To estimate trends in prepregnancy obesity prevalence among women who delivered live births in the US during 2003-2009, by state, age, and race-ethnicity. METHODS: We used Pregnancy Risk Assessment Monitoring System (PRAMS) data from 2003, 2006, and 2009 to measure prepregnancy obesity (body mass index [BMI]≥30kg/m(2)) trends in 20 states. Trend analysis included 90,774 records from 20 US states with data for all 3 study years. We used a chi-square test for trend to determine the significance of actual and standardized trends, standardized to the age and race-ethnicity distribution of the 2003 sample. RESULTS: Prepregnancy obesity prevalence increased by an average of 0.5 percentage points per year, from 17.6% in 2003 to 20.5% in 2009 (P<0.001). Obesity increased among women aged 20-24 (P<0.001), 30-34 (P=0.001) and 35 years or older (P=0.003), and among non-Hispanic white (P<.001), non-Hispanic black (P=0.02), Hispanic (P=0.01), and other women (P=0.03). CONCLUSION: Overall, prepregnancy obesity prevalence continues to increase and varies by race-ethnicity and maternal age. These findings highlight the need to address obesity as a key component of preconception care, particularly among high-risk groups.

Seeing the portal in herpes simplex virus type 1 B capsids.

Resolving the nonicosahedral components in large icosahedral viruses remains a technical challenge in structural virology. We have used the emerging technique of Zernike phase-contrast electron cryomicroscopy to enhance the image contrast of ice-embedded herpes simplex virus type 1 capsids. Image reconstruction enabled us to retrieve the structure of the unique portal vertex in the context of the icosahedral capsid and, for the first time, show the subunit organization of a portal in a virus infecting eukaryotes. Our map unequivocally resolves the 12-subunit portal situated beneath one of the pentameric vertices, thus removing uncertainty over the location and stoichiometry of the herpesvirus portal.

A novel method combining linkage disequilibrium information and imputed functional knowledge for tagSNP selection.

Analyses of high-density SNPs in genetic studies have the potential problems of prohibitive genotyping costs and inflated false discovery rates. Current methods select subsets of representative SNPs (tagSNPs) using information either on potential biologic functionality of the SNPs or on the underlying linkage disequilibrium (LD) structure, but not both. Combining the two types of information may lead to more effective tagSNP selection. The proposed method combines both functional and LD information using a weighted factor analysis (WFA) model. The WFA was applied to the dense SNP collection from 129 genes sequenced by the SeattleSNPs Program for Genomic Application. TagSNPs selected by WFA were compared with those selected by an LD-based method. WFA allowed prioritization of SNPs that would otherwise share equivalent ranking due to underlying LD structure alone. Furthermore, WFA consistently included SNPs not selected by function or by LD alone. A literature review of a subset of genes revealed that SNPs selected by WFA were more likely represented in published reports.

Longitudinal analysis of community health workers' adherence to treatment guidelines, Siaya, Kenya, 1997-2002.

OBJECTIVES: To investigate community health workers' (CHW) adherence over time to guidelines for treating ill children and to assess the effect of refresher training on adherence. METHODS: Analysis of 7151 ill-child consultations performed by 114 CHWs in their communities from March 1997-May 2002. Adherence was assessed with a score (percentage of recommended treatments that were prescribed), calculated for each consultation. Recommended treatments were those that were indicated based on CHW assessments. We used piecewise regression models to evaluate adherence before and after training. RESULTS: The average adherence score was 79.4%. Multivariable analyses indicate that immediately after the first refresher training, the mean adherence level improved for patients with a severe illness, but worsened for patients without severe illness. Adherence scores declined rapidly during the 6 months after the second refresher training. CONCLUSIONS: The first refresher was partially effective, the second refresher had an effect contrary to that intended, and patient characteristics had a strong influence on adherence patterns. Longitudinal studies are useful for monitoring the dynamics of CHW performance and evaluating effects of quality improvement interventions.

The influence of observation and setting on community health workers' practices.

OBJECTIVE: To determine whether results from an evaluation that involved observation of community health workers while they performed patient consultations in a hospital reflected normal everyday practices. DESIGN: Comparison of two samples of ill-child consultations: (i) consultations performed during an evaluation in which we observed community health workers in a hospital in-patient and outpatient department from February to March 2001 and (ii) consultations performed under no observation in villages and documented in clinical registers within the 90 days before the hospital evaluation. SETTING: Siaya District Hospital and villages in Kenya. STUDY PARTICIPANTS: Community health workers. MAIN OUTCOME MEASURE: Treatment error indicator, defined as the percentage of consultations where at least one recommended treatment (where recommended treatments were those that were indicated based on community health worker assessments of the child's condition) was not prescribed. RESULTS: We analyzed data on 1132 consultations (372 from the hospital evaluation and 760 from the community) performed by 103 community health workers. For all types of consultations combined, the difference between treatment error indicators (hospital minus community) was -16.4 [95% confidence interval (CI): -25.6, -7.1]. CONCLUSIONS: We found that community health workers made treatment errors less frequently when they were observed in a hospital in-patient or outpatient department than when they were not observed in the community. Evaluations that involve the observation of community health workers in a hospital setting might overestimate the quality of care that they normally give in their villages.

Obstetric deaths in Bangladesh, 1996-1997.

OBJECTIVES: The purpose of this study was to measure and to describe obstetric deaths in Bangladesh. METHODS: We reviewed hospital records and interviewed health workers in clinic sites and field workers who cared for pregnant women. RESULTS: We obtained case reports of 28998 deaths of women aged 10-50, of which 8562 (29.5%) were maternal deaths. Most (7086, 82.8%) of these deaths were due to obstetric causes. The most common causes of direct obstetric death were eclampsia (34.3%), hemorrhage (27.9%), and obstructed and/or prolonged labor (11.3%). National direct obstetric death rate was estimated to be 16.9 per 100,000 women. CONCLUSIONS: Efforts to reduce fertility in Bangladesh have led to an estimated 49% reduction in the maternal mortality rate per 1000 women during the past 18 years. Variations in maternal mortality suggest the need to develop local strategies to improve obstetric care.

Missed opportunities for congenital syphilis prevention in an urban southeastern hospital.

BACKGROUND: Despite recent declines in syphilis rates nationally, recent outbreaks suggest that prevention of congenital syphilis remains an ongoing public health problem. GOALS: To identify missed opportunities for congenital syphilis prevention during prenatal care. STUDY DESIGN: Retrospective medical record review of 157 live birth or stillbirth deliveries that involved cases of congenital syphilis from Grady Memorial Hospital (Atlanta, GA). RESULTS: The hospital congenital syphilis prevalence was 8.2 cases per 1,000 live births. Six percent of case patients were HIV positive. Opportunities for earlier maternal screening, treatment, or diagnosis were missed in 60% of case patients who received timely prenatal care. Congenital syphilis cases attributable to preventable missed opportunities were significantly more common among case patients with fewer prenatal visits (66% versus 28%, P = 0.01). CONCLUSION: Provider efforts to reduce congenital syphilis in high-risk populations receiving prenatal care should focus on (1) screening patients at the first opportunity, at both the first prenatal visit and during the third trimester (i.e., 28 weeks); (2) performing on-site testing and same-day treatment; (3) providing appropriate treatment to infected women with penicillin allergy; (4) referring sex partners for treatment to prevent reinfection; and (5) screening all pregnant women attending emergency clinics.

The check box: determining pregnancy status to improve maternal mortality surveillance.

OBJECTIVE: More than half of pregnancy-related deaths are not identified through routine surveillance methods. The purpose of this study was to evaluate the effectiveness of the pregnancy check box on death certificates in ascertaining pregnancy-related deaths. METHODS: Data derived from the Centers for Disease Control and Prevention's ongoing Pregnancy Mortality Surveillance System were used to identify states that included a check box on the death certificate in 1991 and 1992. Death certificates from those states were evaluated to determine the number and proportion of pregnancy-related deaths identified by a marked check box. Characteristics of death were also examined. RESULTS: Sixteen states and New York City included a check box or question specifically asking about pregnancy of the decedent. Of the 425 pregnancy-related deaths identified in the 17 reporting areas, 124 (29%) were determined to be pregnancy-related deaths only because of the pregnancy status information provided in the check box. The proportion of deaths identified only by a marked check box ranged from less than 5% for four states to 40% or more for seven states. CONCLUSIONS: The availability of pregnancy status information on death certificates is a simple and effective aid in ascertaining a pregnancy-related death, when no other indicators of pregnancy appear on the death certificate. Routine use of the pregnancy check box for all states would lead to substantially increased classification of maternal deaths and more accurate classification of the causes of and risk factors for maternal deaths.

Injury-related deaths among women aged 10-50 years in Bangladesh, 1996-97.

BACKGROUND: Few studies have examined injury-related deaths among women in Bangladesh. We did a case-finding study to identify causes and the impact of intentional and unintentional injury-related deaths among women aged 10-50 years in Bangladesh. METHODS: Between 1996 and 1997, health care and other service providers at 4751 health facilities throughout Bangladesh were interviewed about their knowledge of deaths among women aged 10-50 years. In addition, at all public facilities providing inpatient service, medical records of women who died during the study period were reviewed. The reported circumstances surrounding each death were carefully reviewed to attribute the most likely cause of death. FINDINGS: 28,998 deaths among women aged 10-50 years were identified in our study, and, of these, 6610 (23%) were thought to be caused by intentional or unintentional injuries. About half (3317) of the injury deaths were attributable to suicide, 352 (5%) to homicide, 1100 (17%) to accidental injuries, and the intent was unknown for 1841 (28%) deaths. The unadjusted rate of suicides were higher in the Khulna administrative division (27.0 per 100,000) than the other four administrative divisions of Bangladesh (range 3.5-11.3 per 100,000). Poisoning (n=3971) was the commonest cause of injury-related death--60% of all injury deaths (6610) and 14% of all deaths (28,998). Other common causes of injury deaths in order of frequency were hanging or suffocation, road traffic accidents, burns, drowning, physical assault, firearm or sharp instrument injury, and snake or animal bite. INTERPRETATION: Intentional and unintentional injuries are a major cause of death among women aged 10-50 years in Bangladesh. Strategies to reduce injury-related deaths among women need to be devised.

Tetanus and pregnancy-related mortality in Bangladesh.

A national survey of health-care providers in Bangladesh identified 298 women who died from pregnancy-related tetanus. Immunising all girls with tetanus toxoid and providing safe menstrual regulation services would prevent such deaths.

PIP: This letter discusses pregnancy-related tetanus mortality in Bangladesh. A national survey of health care providers identified 298 women from 5 urban infectious disease hospitals who had died from pregnancy-related tetanus after an induced abortion or during the postpartum period. In response to the problem, the Bangladesh government has provided a tetanus toxoid vaccination program for pregnant women to prevent neonatal and postpartum tetanus and has begun training health workers to perform menstrual regulation procedures. Considering the contribution of traditional abortion practices to tetanus death in Bangladesh, a proposal on maternal tetanus prevention policies would be most effective if it included safe menstrual regulation services and provision of tetanus toxoid immunization to all girls before they reach reproductive age (i.e., at age 12).

Maternal cigarette smoking and invasive meningococcal disease: a cohort study among young children in metropolitan Atlanta, 1989-1996.

OBJECTIVES: This study assessed the association between maternal cigarette smoking during pregnancy and the risk of invasive meningococcal disease during early childhood. METHODS: Using a retrospective cohort study design, cases from an active surveillance project monitoring all invasive meningococcal disease in the metropolitan Atlanta area from 1989 to 1995 were merged with linked birth and death certificate data files. Children who had not died or acquired meningococcal disease were assumed to be alive and free of the illness. The Cox proportional hazards analysis was used to assess the independent association between maternal smoking and meningococcal disease. RESULTS: The crude rate of meningococcal disease was 5 times higher for children whose mothers smoked during pregnancy than for children whose mothers did not smoke (0.05% vs 0.01%). Multivariate analysis revealed that maternal smoking (risk ratio [RR] = 2.9; 95% confidence interval [CI] = 1.5, 5.7) and a mother's having fewer than 12 years of education (RR = 2.1; 95% CI = 1.0, 4.2) were independently associated with invasive meningococcal disease. CONCLUSIONS: Maternal smoking, a likely surrogate for tobacco smoke exposure following delivery, appears to be a modifiable risk factor for sporadic meningococcal disease in young children.

No fathers' names: a risk factor for infant mortality in the State of Georgia, USA.

Many studies have explored maternal and infant factors as risks for infant mortality, but little attention is given to paternal factors. In Georgia, listing a father's name on the birth certificate is optional for married couples and possible after paternal acknowledgment for unmarried couples. The authors evaluated father's name reporting as a paternity measure and risk for infant mortality. Using the linked 1989-1990 birth and death certificates of singleton Georgia infants to calculate relative risks (RRs), infant mortality rates for 38,943 infants with no father's names listed were compared to rates for 178,100 with father's names listed. Compared with the rate for married women listing names, the death rates were higher for unmarried mothers not listing fathers (relative risk, RR = 2.5; 95% CI 2.3-2.7), unmarried mothers listing fathers (RR = 1.4; 95% CI 1.3-1.6), and married women not listing fathers (RR = 2.3; 95% CI 1.6-3.1). Increased risks remained after stratifying by maternal race, age, adequacy of prenatal care and medical risks; and congenital malformations, birthweight, gestational age, and small-for-gestational age. Using logistic regression to examine for effect modification and to adjust for these factors together, the adjusted relative risks for death varied across different groups without fathers' names, regardless of marital status. For example, it remained statistically higher for infants with no father listed and without effect-modifying conditions such as low birthweight (estimated RR = 2.0; 95% CI 1.6-2.4). Although these findings suggest paternal involvement, as measured by listing fathers' names, is protective against low birthweight and infant mortality, further evaluation is needed.

Trends and predictors of infant sleep positions in Georgia, 1990 to 1995.

BACKGROUND: In recent years, the prone sleeping position has emerged as the strongest modifiable risk factor for sudden infant death syndrome, the leading cause of infant mortality between 1 month and 1 year of age in the United States. Since April 1992, sudden infant death syndrome risk-reduction strategies have included the promotion of the back or side sleeping position (nonprone) for healthy infants younger than 1 year of age. Most recently, the back position has been advocated as the best sleeping position and the side position as an alternative. METHODS: To evaluate trends in prevalence of the prone position from 1990 to 1995, we used data available from the Georgia Women's Health Survey, a random digit-dialed telephone survey of 3130 women 15 to 44 years of age. We examined the position in which women put their infant to sleep in the first 2 months of life for their most recent live birth (N = 868) and determined independent predictors of prone sleep position among women who consistently used the prone or the back/side position (n = 636) using multiple logistic regression. RESULTS: The prevalence of mothers who put their infant to sleep in the prone position significantly decreased, from 49% in 1990 to 15% in 1995. This decrease is primarily attributable to a major shift to the side position rather than to the back. Using multiple logistic regression, we found the prone sleeping position to be significantly higher among women who entered prenatal care after the first trimester (odds ratio [OR], 3.6; 95% confidence interval [CI], 1.4-9.2), were black (OR, 2.1; 95% CI, 1.4-3.1), had less than a high school education (OR, 2.2; 95% CI, 1.4-3.4), and were living in rural Georgia (OR, 1.9; 95% CI, 1.3-2.7). For the period after April 1992, women who had previous children were 2.6 (OR, 95% CI, 1.7-4.1) times more likely to use the prone sleep position than were first-time mothers. CONCLUSIONS: The prevalence of the use of the prone sleep position for infants decreased significantly over the study period. This decrease coincided with national efforts to promote the back or side sleeping position. Increased efforts should target groups who are more likely to use the prone position to attain the national goal of

Child fatality review in Georgia: a young system demonstrates its potential for identifying preventable childhood deaths.

BACKGROUND: Child fatality review (CFR) by interagency teams can contribute to the prevention of childhood deaths. We investigated the potential usefulness of Georgia's CFR, legislated in 1990 primarily to prevent death from child maltreatment, for identifying preventable deaths from injury and sudden infant death syndrome (SIDS). METHODS: Using CFR report data and death certificate data, we examined reviewed and nonreviewed childhood deaths in Georgia in 1991 and examined data by etiology, county, risk factors, and preventability. RESULTS: Injury or SIDS caused 33.2% of childhood deaths in Georgia in 1991; CFR reviewed 29.4% of these. Child fatality review was most sensitive for investigating death from intentional injury (40.5%) and SIDS (35.3%). Review teams reassigned the cause of five deaths (2.0%) to child abuse or neglect. County participation was low (31.4%). Overall, 29.0% of deaths were judged preventable. CONCLUSIONS: Georgia's CFR has potential for identifying preventable childhood deaths. Refinements in the system can increase the number and accuracy of death investigations. By participating in the system, physicians may make meaningful contributions to preventing childhood death in their own communities.

Differences in the risk of homicide and other fatal injuries between postpartum women and other women of childbearing age: implications for prevention.

OBJECTIVES: This study compared injury deaths between postpartum women and other women aged 15 to 44. METHODS: Risk ratios and 95% confidence intervals (CIs) were computed for injury fatality rates. RESULTS: Fifty percent (29/58) of postpartum injury deaths were homicides, compared with 26% (427/1648) of injury deaths among nonpregnant, nonpostpartum women. For females aged 15 to 19, the homicide rate was 2.6 times higher (95% CI = 1.17, 5.95) for postpartum females than for other females. The motor-vehicle fatality rate was lower for postpartum females than for nonpregnant, nonpostpartum females (risk ratio = 0.30, CI = 0.18, 0.48). CONCLUSIONS: Postpartum females aged 15 to 19 years were at higher risk of homicide. Postpartum women were at reduced risk of motor-vehicle fatalities.

Delayed entry into prenatal care: effect of physical violence.

OBJECTIVE: To assess whether women who experienced physical violence by their partner during the 12 months before delivery were more likely to delay entry into prenatal care than were women who had not experienced physical violence. METHODS: We analyzed data from the Pregnancy Risk Assessment Monitoring System. The sample included 27,836 women who delivered live infants during 1993-1994 in nine states and were surveyed 2-6 months after delivery. We calculated risk ratios and 95% confidence intervals (CIs) to measure the association between physical violence within the 12 months before delivery and entry into prenatal care. RESULTS: The prevalence of delayed entry into prenatal care (entering after the first trimester) was 18.1% and that of reported physical violence was 4.7%. Overall, women who experienced physical violence were 1.8 times more likely (95% CI 1.5, 2.1) to have delayed entry into prenatal care than women who had not experienced such violence. When stratifying by selected maternal characteristics, this association was found only for groups of women who were 25 years of age or older or were of higher socioeconomic status. CONCLUSION: Older women and women of higher socioeconomic status who reported physical violence were more likely to delay entry into prenatal care than younger or less affluent women.

Quality assessment of fetal death records in Georgia: a method for improvement.

OBJECTIVES: Although more fetal deaths than neonatal deaths occur, routinely collected fetal death data are seldom used for perinatal epidemiologic research because of data quality concerns. We developed a strategy for identifying and correcting errors in birthweight and gestational age in fetal death records. METHODS: Using data from Georgia for 1989 and 1990, we detected singleton fetal death records having improbable or missing birthweight or gestational age by comparing these values with referent values. To verify the questionable values, we contacted 100 reporting hospitals in 1992. RESULTS: In 817 of 2226 records, values were either improbable (60.1%) or missing (39.9%). We were able to contact the hospitals to verify data for 716 (88%) of these records. Verification resulted in corrections to 405 (57%) records, and 48% of unreported birthweights were obtained. CONCLUSIONS: Many errors in recorded gestational age and birthweight were identified by this method. Rather than deleting or inputting problem data for analyses, researchers should consider efforts to verify them. Efforts to improve this information should include improved reporting, strict quality assurance, and procedures for routine verification and correction of records.

An evaluation of the use of dried blood spots from newborn screening for monitoring the prevalence of cocaine use among childbearing women.

A collaborative March of Dimes study was designed to examine the utility of dried blood spot (DBS) materials routinely collected from newborns as a source for monitoring cocaine exposure and to assess the prevalence of cocaine use among childbearing women in Georgia. We used a modified urinary radioimmunoassay (RIA) to anonymously detect the cocaine metabolite benzoylecgonine (BE) in DBSs. Extensive efforts were undertaken to assure absolute nonlinkage of BE data to any individual. The positive results found by RIA were confirmed by a mass spectrometry (MS) method specifically developed to detect BE in DBSs. BE was measured in 23,141 DBSs collected during 2 months of routine newborn screening in Georgia. A good correlation was observed for RIA results versus MS results (r2 = 0.97). The estimated minimal statewide BE prevalence was 4.8 per 1000 childbearing women. We demonstrated that immunoassay testing for cocaine without confirmatory testing can yield falsely elevated prevalence rates. When proper confirmatory testing is done, DBSs are a valuable source for population-based monitoring of substance abuse among childbearing women.

Patterns of prenatal care initiation in Georgia, 1980-1992.

OBJECTIVE: To determine whether characteristics in a woman's first pregnancy were associated with the trimester in which she initiated prenatal care in her second pregnancy. METHODS: Data for white and black women whose first and second pregnancies resulted in singleton live births between 1980 and 1992 were obtained from Georgia birth certificates (n = 177,041). Adjusted relative risks (RRs) for early prenatal care in the second pregnancy were computed by logistic regression models that included trimester of prenatal care initiation, infant outcomes, or maternal conditions in the woman's first pregnancy as the exposure and controlled for maternal age, education, child's year of birth, interval between first and second pregnancy, presence of father's name on the birth certificate, and the interaction between prenatal care and education. Models were stratified by race. RESULTS: Women of both races who initiated prenatal care in the first trimester of their first pregnancies were more likely than those with delayed care to initiate prenatal care in the first trimester of their second pregnancies (RR = 1.25 and 1.63 for white and black women educated beyond high school, respectively). Both white and black women who delivered a baby with very low birth weight (RR = 1.06 and 1.15, respectively) or who suffered an infant death (RR = 1.09 and 1.31, respectively) in their first pregnancies were more likely than those who did not experience these events to begin prenatal care in the first trimester of their second pregnancies. CONCLUSION: Women with some potentially preventable adverse infant outcomes tend to obtain earlier care in their next pregnancy. Unfortunately, women who delayed prenatal care in their first pregnancy frequently delay prenatal care in their next.