Socio-demographic risk factors for perinatal mortality. A study of perinatal mortality in the French district of Seine-Saint-Denis.

OBJECTIVES: To investigate the impact of a set of socio-demographic risk factors commonly associated with perinatal mortality -- age, parity, marital status, educational attainment, occupation, and ethnic origin in the French district of Seine-Saint-Denis. METHODS: The study has a case-control design with prospective identification of cases. It includes all singleton non-malformed perinatal deaths which occurred between October 1, 1989 and September 30, 1992. Logistic regression is used to estimate odds ratios. Base incidence rates are generated by incorporating sampling information for the controls. RESULTS: All socio-demographic variables are significantly related to the risk of perinatal mortality in univariate analyses. Some of the increased risk due to social factors is explained by differential age and parity distributions. In multivariate models, however, only parity and country of origin are significant. Women born in the French overseas departments and territories and Sub-Saharan Africa have the highest odds ratios. CONCLUSIONS: Women born outside of continental France face an elevated risk of experiencing a perinatal death even after controlling for age, parity and socioeconomic factors. Although, this excess risk may reflect residual variation in socioeconomic status, alternative explanations such as standards of prenatal care, medical problems during pregnancy and delivery, and cultural practices should be explored.

[Epidemiology of fetal deaths in the Seine-Saint-Denis perinatal survey]. / Epidémiologie des morts foetales avant le travail dans l'enquête pèrinatale de la Seine-Saint-Denis.

OBJECTIVE: To analyse the epidemiological characteristics of antepartum stillbirths. DESIGN: A population based cases-cohort study in a limited geographical area, the department of Seine-Saint-Denis, France. Prospective collection of cases and controls between the 1989-10-01 and 1992-09-30, and retrospective collection of data. SUBJECTS: All antepartum stillbirths of 28 weeks gestation of greater, except lethal malformations and multiple pregnancies. RESULTS: 273 antepartum stillbirths were collected during the 3-year study period (52, 2% of the perinatal deaths). The causes were mainly, abruptio placenta and cordonal causes; however, unexplained antepartum stillbirth was the most important group (38, 8%). Hypotrophy was present for 49.5% of cases versus 10.1% of controls (p < 0.001). It was associated with death whatever cause or gestational age, particularly in unexplained antepartum death (54.7%). In univariate analysis, the usual risk factors including obstetrical history, socio-economic characteristics, obstetric care and country of birth were associated with death. But, in multivariate analysis, only "no pregnancy déclaration", "deficient obstetric care", "history of stillbirth", "born in Black Africa" and "born in DOM-TOM" were significantly associated with death. CONCLUSION: More than one half of perinatal deaths concern antepartum stillbirth; the causes have remained unchanged for twenty years and unexplained antepartum stillbirth remains the most important group. The principal risk factor is fetal hypotrophy. The other significant risk factors after multivariate analysis are deficient obstetric care and birth in Black Africa or in the DOM-TOM. To propose prevention actions, progress is necessary in in utero diagnostic of hypotrophy and in the understanding in the risk associated with country of origin.

Determinants of meconium-stained amniotic fluid in term pregnancies.

This study examines ethnic variations in meconium-stained amniotic fluid in term pregnancies, taking into account the role of gestational age, maternal sociodemographic characteristics, and medical risk factors. The study population included black and white singleton live births (N = 14,419) between 37 and 42 weeks' gestation, delivered vaginally at the Medical University of South Carolina from 1982 through 1990. Chi-square and logistic regression analysis were used to examine the association between the independent variables and meconium-stained amniotic fluid (MSAF). An increased risk of MSAF was found for advancing gestational age, indicators of fetal stress, fewer than five prenatal care visits, and > 15 hours labor. After controlling for demographic and clinical characteristics, the risk of MSAF in black patients was approximately 1.5 times that of white patients. The higher proportion of MSAF in blacks could not be explained with obvious risk factors.

Hyaline membrane disease in black newborns: does fetal lung maturation occur earlier?

Debate has developed among several authors about possible accelerated maturation of black fetuses in comparison with whites. In Guadeloupe, French West Indies, where 85% of the population is of black African-American origin, it has been noted that the incidence of hyaline membrane disease (HMD) represents a significant drop beginning after the 32nd week of gestation. Over a 3-year period, 419 black low-birthweight singleton newborns were admitted in the University Hospital's Neonatal Department covering 70% of all births of the island. The incidence of HMD was 50% among very low birthweight (< 1500 g) and 8.3% among moderate low birthweight (> or = 1500 g; P < 0.001). The incidence of HMD was 48.8% among the very preterm (< 32 weeks) and 7.8% (26/331) among the moderate preterm (> or = 32 weeks; P < 0.001). These differences were similar for appropriate for gestational age and small for gestational age infants. Significant differences remained after controlling for several maternal risk factors. These results suggest that the 32nd week of gestation represents a significant drop in the risk for respiratory distress syndrome in black premature compared with that reported in literature on European infants (34th week) and therefore may implicate different obstetrical decisions in the management of critical pregnancies in this population.

Paternity patterns and risk of preeclampsia in the last pregnancy in multiparae.

Few authors have published investigations regarding a possible association between preeclampsia and changing paternity. This study employs an epidemiological approach to explore the relationship between severe preeclampsia and changes in paternity patterns among multigravidae in a Caribbean community (Guadeloupe, French West Indies). Multiparae who were diagnosed with preeclampsia or eclampsia with fetal complications (transfer of their infants in the Neonatal Department) and controls were examined (134 mothers' interviews). Information concerning paternity for the index and previous pregnancies was collected from three groups: women with pregnancy-induced hypertension (PIH); women with chronic hypertension (CH); and a control group consisting of women without hypertension during pregnancy. In 21/34 (61.7%) of PIH mothers, the father of the current pregnancy was different than that of the former, compared to 4/40 (10%) among CH and 10/60 (16.6%) in the controls (P < 0.0001). Moreover, considering three and four consecutive pregnancies, there was a significant trend (P < 0.005 and P < 0.02) for an increase in PIH with having a different father in each successive pregnancy. Patterns of changing paternity were significantly correlated with pregnancy-induced hypertension in multiparae but not with chronic hypertension and controls.

[Pathology of travelers in the Antilles. Role of imported metropolitan pathology]. / Pathologie du voyageur aux Antilles. Place de la pathologie métropolitaine importée.

A preliminary and retrospective review--with a southern perspective--of some traveller's pathologies, mostly imported, and leading to hospital admission in Guadeloupe (FWI). End stage patients (cancer, AIDS...) frequently travel for a last, "compassional" trip. Ischemic heart disease is the leading pathology imported from the mother country (France). As well as in diabetes or psychiatric illness, destabilization frequently occurs as a consequence of travel (jet lag). Compulsive tennis plus dehydration cause the very common stone passage of nephrolithiasis. Concern is growing for heroin withdrawal syndrome or cocaine (crack)-abuse, and for supply for rare and expensive anticancer, antigraft rejection or antinfective (AIDS) agents. Much more familiar to us are photodermatitis, larva migrans, dengue, or ciguaterra, locally acquired. On the other hand some pathologies are quite "exotic" to us: Kaposi sarcoma, Lyme, or Behçet disease, familial mediterranean fever, brucellosis.

Ethnic variation in postnatal assessments of gestational age: a reappraisal.

While the possibility of an ethnic bias in postnatal assessments of gestational age has been suggested by several investigators, others have reported that postnatal assessments do not provide biased estimates in non-White ethnic groups. In the light of this ongoing controversy, this study examines the validity of the Ballard postnatal assessment of gestational age by ethnicity, using a relatively large hospital data base that allows for the inspection of ethnic variations in the agreement between the Ballard assessment and last menstrual period (LMP). The results indicate that there is a greater over-estimation of the LMP interval by the Ballard method in Blacks compared with Whites and suggest that systematic differences exist by ethnicity of mother in the agreement between the Ballard postnatal assessment and the LMP interval. After taking maternal characteristics and pregnancy complications into account, for a given gestational age interval, Blacks have on average a greater level of maturity as measured by Ballard. One interpretation of these findings is that postnatal assessments may provide biased over-estimates of the LMP gestational age interval in certain ethnic groups. An alternative interpretation of these data is that the gestational age interval based on LMP is not a valid indicator of fetal maturity, readiness for birth and infant risk status across all ethnic groups.

Validity of postnatal assessments of gestational age in low birthweight infants from a Caribbean community.

The Dubowitz assessment of gestational maturity was compared with the best obstetric estimate of gestational age based on date of last menstrual period (LMP) or ultrasonography performed early in the pregnancy or both. This study involved 384 low birthweight infants admitted to the neonatal tertiary center in Guadeloupe, French West Indies, during the period 1986 through 1988. The Dubowitz assessment exceeded the best obstetric estimation by an average of nearly 5 days. This overestimation by the Dubowitz method was observed at every gestational age and was greatest at gestational ages of less than 35 weeks. The physical characteristics of the postnatal assessment were in closer agreement with the best obstetric estimate than the neurological characteristics. These findings concur with other investigations that indicate that the Dubowitz postnatal assessment of gestational age overestimates the gestational age interval from date of LMP in low birthweight and preterm infants.

PIP: Physicians used data on 384 low birth weight neonates born between January 1986 and December 1988, who were in the neonatal intensive care unit at Pointe-a-Pitre Hospital in Guadeloupe, to compare the Dubowitz assessment of gestational age with the best obstetric estimate of gestational age. They needed a valid estimate of gestational age to quickly differentiate premature newborns from small-for-dates newborns. The hospital had limited technical and human resources, so it needed to determine which infants were at greater risk. The Dubowitz assessment resulted in a mean gestational age about 5 days longer than the obstetric estimate. There was almost a 2 week difference in mean gestational age between the neurological component and the physical component of the Dubowitz assessment (35 weeks, 4 days vs. 33 weeks, 5 days). The 2 estimates agreed completely in just 25% of cases. They disagreed by at least 2 weeks in 18% of the cases and by at least 3 weeks in 8% of cases. The analysis indicated that the Dubowitz assessment consistently overestimated gestational age in both low birth weight and premature infants and that the mean difference increased as gestational ages fell. The Dubowitz assessment even had this effect when the researchers separated the newborns into those whose gestational age was based just on last menstrual period (LMP) and those whose gestational age was based just on last (LMP) confirmed by ultrasound at a gestational age 20 weeks. The neurological component significantly overestimated both the combined Dubowitz and obstetric values for premature infants, while the physical component tended to agree.

Validity of postnatal assessments of gestational age: a comparison of the method of Ballard et al. and early ultrasonography.

This study investigates the accuracy of the postnatal gestational age assessment method of Ballard et al. to predict very preterm, preterm, term, postterm, and small-for-gestational-age infants, with gestational age by early ultrasonography used as the gold standard. Sensitivity, specificity, and predictive value were examined for each gestational age category, with 4193 single live births occurring during the period from 1982 through 1989 with an ultrasonographic examination done by 20 weeks' gestation and a postnatal assessment at 28 to 44 weeks. These data indicate that the postnatal assessment overestimated the gestational age of preterm births, resulting in an underestimation of very preterm and preterm percentages. Nearly three fourths of the postterm births by ultrasonography were misclassified by the method of Ballard et al. because of underestimation of postterm gestational ages. These data indicate that, for research purposes, appreciable misclassification of preterm, postterm, and small-for-gestational-age infants will occur if gestational age is determined by the technique of Ballard et al.

The Guadeloupean perinatal mortality audit: process, results, and implications.

In 1983, we implemented an ongoing perinatal mortality audit in Guadeloupe to identify factors underlying the current level of poor perinatal outcome and to stimulate increased provider motivation. The audit was part of an active research approach to document the specific nature of the perceived perinatal health problem, to modify provider behavior through the use of this acquired information, and, ultimately, to decrease avoidable perinatal deaths. We investigated all 320 perinatal deaths in Guadeloupe during 1984 and 1985. Nearly one-half of the perinatal deaths reviewed were determined to be related to maternal high blood pressure, maternal/fetal infection, and preterm delivery. Slightly more than one-half of the perinatal deaths were considered to be avoidable. Over the course of the audit, perinatal mortality rates exhibited a marked decline. The findings of this study support claims that perinatal audits with confidential inquiries may help effect change in perinatal health status in a population; the findings also call attention to the potential benefits of incorporating motivational incentives into these activities.

PIP: In 1983, the authors implemented an ongoing perinatal mortality audit in Guadeloupe to identify factors underlying the current level of poor perinatal outcome and to stimulate increased provider motivation. The audit was part of an active research approach to document the specific nature of the perceived perinatal health problem, to modify provider behavior through the use of this acquired information, and, ultimately, to decrease avoidable perinatal deaths. The authors investigated all 320 perinatal deaths in Guadeloupe during 1984-85. Nearly 1/2 of all perinatal deaths reviewed were determined to be related to maternal high blood pressure, maternal/fetal infection, and preterm delivery. Slightly more than 1/2 of the perinatal mortality rates exhibited a marked decline. The findings of this study support claims that perinatal audits with confidential inquiries may help effect change in perinatal health status in a population; the findings also call attention to the potential benefits of incorporating motivational incentives into these activities.

Anamnestic pregnancy risk assessment.

Based on data obtained from the 1984-1985 Guadeloupean Perinatal Audit, a pregnancy risk scoring system was developed using maternal demographic, socioeconomic, obstetric history and risk characteristics recorded at the first prenatal visit. Various combinations of risk factors were identified for four distinct pregnancy outcomes (perinatal mortality, low birth weight, preterm delivery and intra-uterine growth retardation). The findings emphasize the importance of developing risk assessments for discrete pregnancy outcomes within specific populations.

[An example of research and actions related to perinatal mortality in Guadeloupe. Factors and profiles of sociodemographic risk]. / Un exemple de recherche-action sur la mortalité périnatale en Guadeloupe. II. Facteurs et profils de risque socio-démographiques.

Perinatal risk factors in Guadeloupe (French West Indies) have been analysed from a community-based case-control survey. Two hundred and sixty four perinatal deaths were involved along with 605 controls. Principal component factor analysis of individual risk characteristics was used to identify risk group profiles. These risk profiles were: "single women of low socio-economical status" (17% of the variability), "traditional Caribbean housewives" (14%), "single adolescents" (7%), and "immigrant women" (10%). Only the three first were significantly associated with a poor outcome for the current pregnancy. This approach may be fruitful in planning for public health interventions to prevent perinatal risk. Also, risk profile concepts may be well-accepted by physicians and care providers, in routine practice, for screening of individual at-risk patients.

[An example of the effect of research on perinatal mortality in Guadeloupe (1984-1985). I. Objectives and methodology]. / Un exemple de recherche-action sur la mortalité périnatale en Guadeloupe (1984-1985). I. Objectifs et méthodologie.

Research with a view to action being taken was carried out in Guadeloupe in 1984 and 1985 to try to find out the causes of the high level of perinatal mortality which persists on the island before suggesting to the public health authorities what action to take. All the cases of perinatal mortality (above 500 g in weight) were looked at and analysed carefully according to a protocol that had been prepared. The events preceding the perinatal death were described and also the antenatal and intranatal as well as immediate post-natal care given to the children. A control case was studied for each case that had been registered and the same questionnaire was filled in. The present work shows the methodology used to carry out the enquiry and how it was organized with the collaboration of all the actors in the public health department as well as the doctors and the health authorities authorities.