Heinz W. Berendes

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.

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.

Neuropsychological deficits in children of diabetic mothers

Abstract The question, whether maternal diabetes adversely affects intrauterine brain development as reflected in I.Q. of children, was studied prospectively. Complications of diabetes, such as severity (Whites classification), acetonuria, insulin reaction, and prematurity, were studied. Subjects were matched with nondiabetic controls for hospital of birth, race, sex, socieconomic index, birth order, and maternal age. Diabetic mothers with acetonuria (N = 62) had offspring with lower I.Q. ( X ¯ = 93) than controls ( X ¯ = 102), (p < 0.001). However, the offspring of diabetic patients without acetonuria (N = 44) had I.Q. equal to their controls ( X ¯ = 101). The association between maternal diabetes complicated by acetonuria and I.Q. of the children was present in mild (including gestational) as well as in severe diabetes. No significant effect of insulin reactions in the mother on I.Q. of the offspring was demonstrated. The association of diabetes with acetonuria in respect to I.Q. of offspring was independent of duration of pregnancy.

Effect of age, parity, and smoking on pregnancy outcome: A population-based study

OBJECTIVES The purpose of our study was to investigate the combined interactive effects of maternal age, parity, and smoking on pregnancy outcome. STUDY DESIGN This was a population-based Swedish study (n = 538,829). RESULTS Multiple logistic regression analysis showed that the smoking-related effect on the relative increase in the odds ratio of low birth weight and preterm delivery was significantly greater among multiparous patients than nulliparous; among multiparas, smoking increased the odds ratios for low birth weight and preterm delivery by 2.4 and 1.6; the corresponding relative increases in the odds ratios among nulliparas were 1.7 and 1.1, respectively. With advancing maternal age there was a smoking-related relative increase in the odds ratios for small-for-gestational-age births. Moreover, the age effect on the relative increase of low birth weight, preterm delivery, and small-for-gestational-age births was greater among nulliparas than multiparas. CONCLUSIONS Older smokers are at an especially high risk for small-for-gestational-age births, and parous smokers are at an especially high risk for low birth weight and preterm delivery.

Fetal morbidity following potentially anoxigenic obstetric conditions

Abstract A total of 277 patients with bronchial asthma complicating pregnancy from 30,861 Collaborative Research Project deliveries were analyzed for the fetal effects of the disease. While the risk of prematurity was not significantly increased, the 16 perinatal deaths represent a rate which was twice that of the Project. There was a suggestive increase in the percentage of infants with abnormal neurological findings at one year of age. During the first year, 5.7 per cent of the survey infants developed asthma and 18.4 per cent had severe respiratory diseases, respectively (7 times and 2 times the expected frequency). Asthma complicating pregnancy occurred more frequently among the Puerto Rican patients, but it had more severe effects among the Negro patients on the Project. Severe asthma (16 patients) was a serious threat to the survival and well-being of the fetus and mother. Of 6 patients who died during the study period, 4 were severely asthmatic and 7 of 14 infants from the latter group died perinatally or were neurologically abnormal at one year.

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.

Maternal recall of infant feeding events is accurate.

STUDY OBJECTIVE--Retrospective infant feeding data are important to the study of child and adult health patterns. The accuracy of maternal recall of past infant feeding events was examined and specifically the infants age when breast feeding was stopped and formula feeding and solid foods were introduced. DESIGN AND SETTING--The sample consisted of Bedouin Arab women (n = 318) living in the Negev in Israel who were a part of a larger cohort participating in a prospective study of infant health and who were delivered of their infants between July 1 and December 15, 1981. Data from interviews conducted 12 and 18 months postpartum were compared to the standard data collected six months postpartum. MAIN RESULTS--As length of recall increased there was a small increase in the mean difference, and its standard deviation, between the standard and recalled age when breast feeding was stopped and formula feeding and solid foods were started. Recall on formula feeding was less accurate than recall on solid foods and breast feeding. In particular, among those 61% reporting formula use at the six month interview, 51% did not recall introducing formula when interviewed at 18 months. The odds ratio (95% CI) of stunting versus normal length for age for formula fed versus breast fed infants based on recall data (OR = 2.07; 95% CI 0.82-5.22) differed only slightly from those based on the standard data (OR = 2.21; 95% CI 0.77-6.37). The accuracy of a mothers recall varied with her childs nutritional status at the time of the interview, but not with other sociodemographic, infant, or interviewer characteristics. CONCLUSIONS--Retrospective infant feeding data based on maternal recall of events up to 18 months in the past can be used with confidence in epidemiological studies. However, data on formula feeding may not be as accurate as data on breast feeding and solid food feeding, and accuracy may decrease as length of recall increases.

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. infant, injury, suffocation, motor vehicle, homicide, drowning, inhalation, fire.

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.

A Prospective Study of Spontaneous Fetal Losses after Induced Abortions

The incidence of spontaneous abortions was observed among 31,917 women followed from their first prenatal visit. Life-table analysis showed that losses in the first trimester were not significantly affected by previous induced abortions, nor was any change in the risk of second-trimester losses detected among the 1493 parous women who reported having had induced abortions after childbirth. There was, however, an increase in the incidence of midtrimester losses among the 2019 nulliparous women with previous induced abortions; the age-adjusted rate of loss was 59.9 per 100,000 women at risk per day, as compared with 24.2 among the 12,042 control nulliparous women (P less than 0.001). The relative risk increased with the number of previous induced abortions and was not explained by the distribution of demographic and social variables. The risk decreased from 3.27 (95 per cent confidence limits, 1.72 to 6.23) after abortions induced before 1973, mainly by dilation and curettage, to 1.42 (0.76 to 2.65) after those done since 1973, when the more gentle technic of cervical dilation by use of laminaria was introduced. These findings indicate that there is little or no risk of spontaneous abortions after induced abortions when performed by current technics.