Maternal serum fructosamine levels and stillbirth: a case-control study of the Stillbirth Collaborative Research Network.

OBJECTIVE: To evaluate the association between maternal fructosamine levels at the time of delivery and stillbirth. DESIGN: Secondary analysis of a case-control study. SETTING: Multicentre study of five geographic catchment areas in the USA. POPULATION: All singleton stillbirths with known diabetes status and fructosamine measurement, and representative live birth controls. MAIN OUTCOME MEASURES: Fructosamine levels in stillbirths and live births among groups were adjusted for potential confounding factors, including diabetes. Optimal thresholds of fructosamine to discriminate stillbirth and live birth. RESULTS: A total of 529 women with a stillbirth and 1499 women with a live birth were included in the analysis. Mean fructosamine levels were significantly higher in women with a stillbirth than in women with a live birth after adjustment (177 ± 3.05 versus 165 ± 2.89 µmol/L, P < 0.001). The difference in fructosamine levels between stillbirths and live births was greater among women with diabetes (194 ± 8.54 versus 162 ± 3.21 µmol/L), compared with women without diabetes (171 ± 2.50 versus 162 ± 2.56 µmol/L). The area under the curve (AUC) for fructosamine level and stillbirth was 0.634 (0.605-0.663) overall, 0.713 (0.624-0.802) with diabetes and 0.625 (0.595-0.656) with no diabetes. CONCLUSIONS: Maternal fructosamine levels at the time of delivery were higher in women with stillbirth compared with women with live birth. Differences were substantial in women with diabetes, suggesting a potential benefit of glycaemic control in women with diabetes during pregnancy. The small differences noted in women without diabetes are not likely to justify routine screening in all cases of stillbirth. TWEETABLE ABSTRACT: Maternal serum fructosamine levels are higher in women with stillbirth than in women with live birth, especially in women with diabetes.

A global reference for caesarean section rates (C-Model): a multicountry cross-sectional study.

OBJECTIVE: To generate a global reference for caesarean section (CS) rates at health facilities. DESIGN: Cross-sectional study. SETTING: Health facilities from 43 countries. POPULATION/SAMPLE: Thirty eight thousand three hundred and twenty-four women giving birth from 22 countries for model building and 10,045,875 women giving birth from 43 countries for model testing. METHODS: We hypothesised that mathematical models could determine the relationship between clinical-obstetric characteristics and CS. These models generated probabilities of CS that could be compared with the observed CS rates. We devised a three-step approach to generate the global benchmark of CS rates at health facilities: creation of a multi-country reference population, building mathematical models, and testing these models. MAIN OUTCOME MEASURES: Area under the ROC curves, diagnostic odds ratio, expected CS rate, observed CS rate. RESULTS: According to the different versions of the model, areas under the ROC curves suggested a good discriminatory capacity of C-Model, with summary estimates ranging from 0.832 to 0.844. The C-Model was able to generate expected CS rates adjusted for the case-mix of the obstetric population. We have also prepared an e-calculator to facilitate use of C-Model (www.who.int/reproductivehealth/publications/maternal_perinatal_health/c-model/en/). CONCLUSIONS: This article describes the development of a global reference for CS rates. Based on maternal characteristics, this tool was able to generate an individualised expected CS rate for health facilities or groups of health facilities. With C-Model, obstetric teams, health system managers, health facilities, health insurance companies, and governments can produce a customised reference CS rate for assessing use (and overuse) of CS. TWEETABLE ABSTRACT: The C-Model provides a customized benchmark for caesarean section rates in health facilities and systems.

Risk factors for spontaneous and provider-initiated preterm delivery in high and low Human Development Index countries: a secondary analysis of the World Health Organization Multicountry Survey on Maternal and Newborn Health.

OBJECTIVE: To evaluate how the effect of maternal complications on preterm birth varies between spontaneous and provider-initiated births, as well as among different countries. DESIGN: Secondary analysis of a cross-sectional study. SETTING: Twenty-nine countries participating in the World Health Organization Multicountry Survey on Maternal and Newborn Health. POPULATION: 299 878 singleton deliveries of live neonates or fresh stillbirths. METHODS: Countries were categorised into very high, high, medium and low developed countries using the Human Development Index (HDI) of 2012 by the World Bank. We described the prevalence and risk of maternal complications, their effect on outcomes and their variability by country development. MAIN OUTCOME MEASURES: Preterm birth, fresh stillbirth and early neonatal death. RESULTS: The proportion of provider-initiated births among preterm deliveries increased with development: 19% in low to 40% in very high HDI countries. Among preterm deliveries, the socially disadvantaged were less likely, and the medically high risk were more likely, to have a provider-initiated delivery. The effects of anaemia [adjusted odds ratio (AOR), 2.03; 95% confidence interval (CI), 1.84; 2.25], chronic hypertension (AOR, 2.28; 95% CI, 1.94; 2.68) and pre-eclampsia/eclampsia (AOR, 5.03; 95% CI, 4.72; 5.37) on preterm birth were similar among all four HDI subgroups. CONCLUSIONS: The provision of adequate obstetric care, including optimal timing for delivery in high-risk pregnancies, especially to the socially disadvantaged, could improve pregnancy outcomes. Avoiding preterm delivery in women when maternal complications, such as anaemia or hypertensive disorders, are present is important for countries at various stages of development, but may be more challenging to achieve.

Multiple primary tumours in women following breast cancer, 1973-2000.

We investigated the predictors of the risk of developing a second primary cancer after breast cancer, this occurring in about 12% of affected women. The analysis included 335 191 females, registered in the National Cancer Institute's Surveillance Epidemiology and End Results (SEER) database, who had been diagnosed with breast cancer. Observed numbers of subsequent cancers in the SEER database with a first breast cancer diagnosed from 1973 to 2000 were compared with the expected numbers based on age-adjusted incidence rates to calculate standardised incidence ratios. Kaplan-Meier curves were conducted to determine the median time until the second primary cancer diagnosis. Average number of years until diagnosis varied by site and by age as well as median years until second cancer diagnosis. Most cancer risks decreased with age, but there was an increase in aging-related cancers such as lung cancer. The median years of follow-up were well beyond the 5-year mark. Breast cancer survivors should be advised of their increased risk for developing certain cancers in their lifetime.

Examining the burdens of gendered racism: implications for pregnancy outcomes among college-educated African American women.

OBJECTIVES: As investigators increasingly identify racism as a risk factor for poor health outcomes (with implications for adverse birth outcomes), research efforts must explore individual experiences with and responses to racism. In this study, our aim was to determine how African American college-educated women experience racism that is linked to their identities and roles as African American women (gendered racism). METHODS: Four hundred seventy-four (474) African American women collaborated in an iterative research process that included focus groups, interviews, and the administration of a pilot stress instrument developed from the qualitative data. Analysis of the qualitative and quantitative data from the responses of a subsample of 167 college-educated women was conducted to determine how the women experienced racism as a stressor. RESULTS: The responses of the women and the results from correlational analysis revealed that a felt sense of obligations for protecting children from racism and the racism that African American women encountered in the workplace were significant stressors. Strong associations were found between pilot scale items where the women acknowledged concerns for their abilities to provide for their children's needs and to the women's specific experiences with racism in the workplace (r = 0.408, p < .001). CONCLUSIONS: We hypothesize that the stressors of gendered racism that precede and accompany pregnancy may be risk factors for adverse birth outcomes.

Stress and preterm delivery: a conceptual framework.

Numerous epidemiological studies of various kinds of stress and preterm delivery have produced either negative or weakly positive results. Those inconclusive findings could be either because of the absence of an association or because of recognised methodological problems that may have masked an association. The biological plausibility of the stress hypothesis provides one rationale for continuing stress research, using better study designs. To further this agenda, we propose an epidemiological model, based on the classic "host, environment, agent" triangle of epidemiological causality. The host is the individual woman, more or less susceptible to stressor-induced pathology. The environment includes the social and cultural conditions that are ongoing stressors as well as social and cultural modifiers of stress e.g. those factors that may influence how a particular stressor is experienced or what the physical response to it may be. The agent is the immediate emotional or physical stressor requiring her response. We draw from recent literature, published principally since 1990, to illustrate this model. This epidemiological model posits that whether the individual is overwhelmed by stressors depends not only on the strength of the agents but also upon host susceptibility to stress, as well as the background level of acute, environmental and contextual stressors, and the moderating influence of host, environmental and contextual resources for handling stress. Future research needs to be based on stress hypotheses that include all sides of the triangle, data collection instruments that adequately capture relevant stressors and stress responses, and analytical techniques capable of handling complex, multilevel relationships.

Risk factors for improper vaccine storage and handling in private provider offices.

CONTEXT: Preventing loss of vaccine potency during storage and handling is increasingly important as new, more expensive vaccines are introduced, in at least 1 case requiring a different approach to storage. Little information is available about the extent to which staff in private physicians' offices meet quality assurance needs for vaccines or have the necessary equipment. Although the National Immunization Program at the Centers for Disease Control and Prevention (CDC) in 1997 developed a draft manual to promote reliable vaccine storage and to supplement published information already available from the CDC and the American Academy of Pediatrics, the best ways to improve vaccine storage and handling have not been defined. OBJECTIVES: To estimate the statewide prevalence of offices with suboptimal storage and handling, to identify the risk factors for suboptimal situations in the offices of private physicians, and to evaluate whether the distribution of a new National Immunization Program draft manual improved storage and handling practices. DESIGN: Population-based survey, including site visits to a stratified, random sample of consenting private physicians' offices. At least 2 months before the site visits, nearly half (intervention group) of the offices were randomly selected to receive a draft CDC manual entitled, "Guideline for Vaccine Storage and Handling." The remainder was considered the control group. Trained graduate students conducted site visits, all being blinded to whether offices were in the intervention or control groups. Each site visit included measurements of refrigerator and freezer temperatures with digital thermometers (Digi-thermo, Model 15-077-8B, Control Company, Friendswood, TX; specified accuracy +/- 1 degrees C). Their metal-tipped probes were left in the center shelf of cold storage compartments for at least 20 minutes to allow them to stabilize. The type of refrigerator/freezer unit, temperature-monitoring equipment, and records were noted, as were the locations of vaccines in refrigerator and freezer, and the presence of expired vaccines. Other information collected included the following: staff training, use of written guidelines, receipt of vaccine deliveries, management of problems, number of patients, type of office, type of medical specialty, and the professional educational level of the individual designated as vaccine coordinator. PARTICIPANTS: Two hundred twenty-one private physicians' offices known by the Georgia Immunization Program in 1997 to immunize children routinely with government-provided vaccines. OUTCOME MEASURES: Estimates (prevalence, 95% confidence interval [CI]) of immunization sites found to have a suboptimally stored vaccine at a single point in time, defined as: vaccine past expiration date, at a temperature of /=9 degrees C in a refrigerator or >/=-14 degrees C (recommended for varicella vaccine) in freezer, and odds ratios (ORs) for risk factors associated with outcomes. We performed chi(2) analysis and Student's t tests to compare the administrative characteristics and quality assurance practices of offices with optimal vaccine storage with those with suboptimal storage, and to compare the proportion of offices with suboptimal storage practices in the groups that did and did not receive the CDC manual. RESULTS: Statewide estimates of offices with at least 1 type of suboptimal vaccine storage included: freezer temperatures measuring >/=-14 degrees C = 17% (95% CI: 10.98, 23.06); offices with refrigerator temperatures >/=9 degrees C = 4.5% (95% CI: 1.08, 7.86); offices with expired vaccines = 9% (95% CI: 4.51, 13.37); and offices with at least 1 documented storage problem, 44% (95% CI: 35.79, 51.23). Major risk factors associated with vaccine storage outside recommended temperature ranges were: lack of thermometer in freezer (OR: 7.15; 95% CI: 3.46, 14.60); use of freezer compartment in small cold storage units (OR: 5.46; 95% CI = 2.70, 10.99); lack of thermometer in refrigerator (OR: 3.07; 95% CI: 1.15,8.20); and failure to maintain temperature log of freezer (OR: 2.70; 95% CI: 1.40, 5.23). Offices that adhered to daily temperature monitoring for all vaccine cold storage compartments, compared with those that did not, were 2 to 3 times more likely to assign this task to staff with higher levels of training, have received a recent visit from the state immunization program, and be affiliated with a hospital or have Federally Qualified Health Center status. In addition, sites using >1 refrigerator/freezer for vaccine storage were more likely to have at least 1 cold storage compartment outside recommended temperature ranges. We found no significant differences in the data reported above between the intervention group (received copy of the draft manual) and the control group (did not receive copy of draft manual), even when controlling for the annual number of immunizations given or the type of office. (ABSTRACT TRUNCATED)

The role of linked birth and infant death certificates in maternal and child health epidemiology in the United States.

Linked birth and infant death certificates allow measurement of birthweight-specific infant mortality. Jack Smith, MS, to whom this issue of the American Journal of Preventive Medicine is dedicated, played a key role in the National Infant Mortality Surveillance (NIMS) project. NIMS provided national data on birthweight-specific infant mortality for the 1980 birth cohort, updated data previously collected by the National Center for Health Statistics (NCHS) for the 1960 birth cohort, and supported NCHS's implementation of an annual linked file in 1983. NIMS illustrated themes in infant mortality that remain important: the role of low birthweight (LBW) as a contributor to infant mortality, the contribution of disparities in LBW and birthweight-specific mortality to black-white gaps in infant mortality, and the nation's greater success in reducing mortality among LBW infants than in preventing LBW. Linked birth and infant death records are used nationally and by states to study an array of maternal and infant health topics, from the quality of vital records to the impact of therapeutic and public health interventions. By supplementing birth and infant death records with linkages to program and hospital discharge data, epidemiologists and health service researchers are extending the utility of vital statistics data to monitor maternal and infant health.

Exploratory analysis of factors associated with teens' repeated childbearing.

This study was designed to explore the factors regarding unique determinants of repeat childbearing among teens. The influence that key people have on subsequent teen childbearing is examined. Data for this research were gathered in focus groups with teen mothers and parents of teen mothers who access the Supplemental Nutrition Program for Women, Infants, and Children (WIC) in Georgia. Based on the results, repeated childbearing appears to occur within the context of poor parent-child relations, conflicting support for the roles teen mothers are expected to assume, limited social pressures for effective fathering, and limited access to social services for all family members. Pregnancy prevention efforts by agencies for teen mothers should coordinate services for the teen mother, her parent, and her partner.

PIP: This study examined in focus groups the determinants of repeat adolescent childbearing in Georgia, US. Data were obtained from a sample of teenage mothers (TMs) and mothers of TMs who used Georgia's Supplemental Nutrition Program for Women, Infants, and Children (WIC). Nine focus groups were conducted among 64 participants and analyzed for content. The convenience sample was recruited from WIC offices in 3 urban and 2 rural counties among WIC mothers with at least 1 child by the age of 17 years. Findings indicate that repeat childbearing is associated with poor parent-child relations, conflicting support for the roles that TMs are expected to fulfill, limited social pressures for effective fathering, and limited access to social services for all family members. TMs mentioned alienation from their own mothers and difficulty in talking about sexual issues. Mothers of childbearing teens expressed anger at their daughters. TMs and their mothers believed that the 1st births should have been delayed. Mothers and grandmothers differed in their thoughts about the burdens of childbearing. Many grandmothers cared for their grandchildren. Fathers were proud of the pregnancy, but less eager to provide supportive roles for their children. Peer acceptance of early childbearing was influential. Most appreciated WIC, but some thought family planning ought to be a requirement for receipt of WIC benefits. Schools did not provide allowances for missed classes, but WIC programs were a supportive environment. Teens believed that health education should focus on risk taking.

Preterm birth in the African-American community.

Preterm births account for a substantial portion of infant mortality, the major difference in mortality between African-American and white births in the United States, and the key reason that US infant mortality exceeds that of other developed nations. Although preterm birth rates are higher in the African-American community for certain known reasons (proportionately more unwanted conceptions, poorer nutrition, less sufficient prenatal care, and stress-associated behavioral risks), most of the excess risk for preterm delivery remains unexplained. Because preterm delivery is poorly understood in general, prevention strategies are limited. Future research directions should explore contextual and social conditions that might be altered to reduce preterm births in the African-American community.

Birthweight-specific infant mortality risks for Native Americans and whites, United States, 1960 and 1984.

We used NCHS natality and linked-birth/death certificate tapes to compare birthweight-specific neonatal and postneonatal mortality risks for Native Americans and whites in 1960 and in 1984. The birthweight distributions for the two groups were similar both years. Native American neonatal mortality risk dropped from 20.2 in 1960 to 5.2 in 1984, and the relative risk for Native Americans with respect to whites fell from 1.31 in 1960 to a nonsignificant difference in 1984. Postneonatal mortality risks for Native Americans fell from 27.5 in 1960 to 6.2 in 1984, with a drop in the relative risk from 5.2 to 2.1. Although the relative improvements for Native Americans were highest in postneonatal survival, Native Americans still had over twice the level of white postneonatal mortality. Birthweight was positively associated with survival for both groups, but the odds of Native American neonatal death were affected less by low and very low birthweights. For both groups, improvements in neonatal mortality were highest at the lower birthweights, while the gains in postneonatal survival benefitted normal and high birthweight infants most.

Is race a risk factor or a risk marker for preterm delivery?

Reasons for the persistent difference in rates of preterm delivery among black and white women are not clear. Known risk factors explain very little of the variance. Recent studies have shown that social class does not fully account for poor pregnancy outcomes among black women. Cultural and environmental factors that vary between the races, but not between the different socioeconomic levels within a race, may account for some of the unexplained ethnic differences in preterm delivery. Any potentially negative exposure that is distributed differentially between racial groups warrants particular attention. The major hypothesis of this research is that US black women are chronically exposed to specific stressors that adversely affect the outcomes of their pregnancies. A psychosocial stress model has been proposed to explain the complex interactions of social, environmental, and medical factors that are unique among women of color. To generate data for the stress model, a research strategy has been designed to identify psychosocial and behavioral risk factors that have a physiologic impact on pregnancy outcome. We propose that race is a marker for this stress but is not in itself a risk factor for preterm delivery.

Interactive effect of race and marital status in low birthweight.

Although unmarried mothers are at risk of delivering low-birthweight (LBW) infants, the meaning and significance of this variable need to be explored in depth. With data on 216,285 infants born to white and black mothers aged 10 to 49 years in Atlanta, Georgia, between 1980 and 1987, we examined the association of LBW and marital status and the effect of race on the association. Education and age were controlled in the analysis in an attempt to isolate the effect of race on the marital status and birthweight association. The crude LBW rate among infants born to unmarried mothers was about twice the rate among infants born to married mothers (132.8 vs 63.9 per 1000 live births). Adjustment singly for maternal race, age, and education gave risk ratios (unmarried vs married) of 1.50, 2.03, and 1.78, respectively. Simultaneous control for all factors led to a hierarchy of education-adjusted risk: unmarried black adult mothers had the highest risk of delivering an LBW infant (2.49), followed by married black adults (1.93), unmarried black teenagers (1.90), married black teenagers (1.67), unmarried white adults (1.65), unmarried white teenagers (1.35), married white teenagers (1.08), and married white adults (1.0; reference group, with an LBW rate of 51.2/1000 live births). Thus, these data demonstrate both a consistently higher risk for black women and an interactive effect of age on the association of marital status and LBW: unmarried status appears to increase the risk of LBW much more among adult women than among younger women. This finding has implications for research and prevention of LBW.

Class, race, and infant mortality in the United States.

As a result of Sweden's efforts to eliminate poverty and to provide comprehensive health care, there are only small social class differences in infant mortality. The wider social differences in US infant mortality are a consequence of less consistent and thorough attempts at social equity and universal health care. US Black infant mortality continues to be twice that of Whites, and the excess may partially result from racism. Public health research should examine the role of racism in infant mortality and develop interventions to eliminate racism and its effects on the health of Black Americans.

Preterm delivery and low birth weight among first-born infants of black and white college graduates.

Reproductive outcomes were investigated in black and white female college graduates, presumed to be of similar socioeconomic status and similar risk profile with respect to environmental factors. Data were gathered by mail survey from graduates (1973-1985) of four Atlanta, Georgia, colleges between February and June 1988. Of 6,867 alumnae to whom questionnaires were mailed, 3,084 responded. A follow-up study of black nonrespondents yielded responses from 14% (335) of those who did not respond to the mail survey. For all graduates with a first live born at the time of survey (n = 1,089), the rates of preterm delivery, low birth weight, and infant mortality were 80.8, 82.6, and 14.6 per thousand births (primigravida), respectively. Compared with white graduates, black graduates had 1.67 times the risk of preterm delivery and 2.48 times the risk of low birth weight. Measures of social and economic status differed significantly by race. However, adjustment for these variables did not reduce the estimated risk for black graduates compared with whites. Analysis of the nonresponder survey suggested that respondent data alone overestimates the incidence of adverse outcomes in blacks; using nonresponder data, relative risks of 1.28 (preterm delivery) and 1.75 (low birth weight) were calculated as lower limits of the increased risk for blacks.

Mortality among infants of black as compared with white college-educated parents.

BACKGROUND: In the United States, black infants are twice as likely to die as white infants; this difference reflects both black infants' higher rates of low birth weight and the higher mortality among black infants of normal birth weight. We studied mortality in infants born to college-educated parents in order to investigate this gap while controlling for sociodemographic variables. METHODS: We used the National Linked Birth and Infant Death Files for 1983 through 1985 to calculate infant mortality rates for children born to college-educated parents. The study population consisted of 865, 128 white infants and 42,230 black infants. A separate effect of birth weight was assessed by examining mortality rates before and after the exclusion of infants weighing less than 2500 g at birth (low-birth-weight infants). RESULTS: In this population, the infant mortality rate was 10.2 per 1000 live births for black infants and 5.4 per 1000 live births for white infants; the adjusted odds ratio for death among black infants was 1.82 (95 percent confidence interval, 1.64 to 2.01). The rate of low birth weight was more than twice as high among blacks (7 percent) as among whites (3 percent), although the mortality rate in this group was not higher among blacks than among whites. Black infants were three times as likely as white infants to die of causes attributable to perinatal events, including prematurity. They were no more likely to die of the sudden infant death syndrome. After the exclusion of low-birth-weight infants, the mortality rates for black and white infants were equal. CONCLUSIONS: In contrast to black infants in the general population, black infants born to college-educated parents have higher mortality rates than similar white infants only because of their higher rates of low birth weight. Black and white infants of normal birth weight have equivalent mortality rates.