Patricia H. Shiono

The direct cost of low birth weight.

Medical and technological advances in the care of infants with low birth weight (less than 2,500 grams, or 5 pounds, 8 ounces) and very low birth weight (less than 1,500 grams, or 3 pounds, 5 ounces) have substantially increased the survival rate for these infants and have led to concerns about the demands their care places upon their families and society. The dollar cost of the resources used disproportionately to care for low birth weight children is one measure of the burden of low birth weight. Using analyses of national survey data for 1988 for children ages 0 to 15, this article presents estimates of the direct incremental costs of low birth weight--costs of the resources used to care for low birth weight infants above and beyond those used for infants of normal birth weight. In 1988, health care, education, and child care for the 3.5 to 4 million children ages 0 to 15 born low birth weight between

The risk of childhood cancer after neonatal exposure to vitamin K.

5.5 and

The effect of physical activity during pregnancy on preterm delivery and birth weight

6 billion more than they would have if those children had been born normal birth weight. Low birth weight accounts for 10% of all health care costs for children, and the incremental direct costs of low birth cost weight are of similar magnitude to those of unintentional injuries among children and in 1988 were substantially greater than the direct costs of AIDS among Americans of all ages in that year.

Does maternal employment affect breast-feeding?

Background Two recent studies have found that infants who received intramuscular vitamin K were at twice the expected risk for cancer during childhood. Since nearly all newborns in the United States receive this drug, the public health implications of this association, if confirmed, would be substantial. Methods We examined the relation between vitamin K and cancer in a nested case-control study that used data from the Collaborative Perinatal Project, a multicenter, prospective study of pregnancy, delivery, and childhood. Among 54,795 children born from 1959 through 1966, 48 cases of cancer were diagnosed after the first day of life and before the eighth birthday. Each case child was matched with five randomly selected controls whose last study visit occurred at or after the age when the case childs cancer was diagnosed. Exposure to vitamin K was determined from study forms and medical records. Results Vitamin K had been administered to 68 percent of the 44 case children and 71 percent of the 226 control...

Father's effect on infant birth weight.

The relationship between physical activity during pregnancy, preterm birth, and gestational age-adjusted birth weight was investigated prospectively in a cohort of 7101 women. This study is one of few to evaluate both employment- and non-employment-related physical activity. Prolonged periods of standing were associated with a modestly increased risk of preterm delivery (adjusted odds ratio for greater than or equal to 8 hours/day of standing = 1.31). Heavy work or exercise was not associated with preterm delivery (adjusted odds ratio for greater than or equal to 4 hours per day of heavy work = 1.04). The proportion of infants born preterm did not differ among women working in predominantly standing, active, and sedentary occupations. Physical activity was not associated with gestational age-adjusted birth weight after controlling for confounding variables. These data suggest that unmeasured socioeconomic differences among women reporting different levels of activity may account for previously described associations between physical activity and pregnancy outcome. Most pregnant women who report increased levels of physical activity are not at increased risk of preterm delivery or reduced intrauterine growth. However, these data do not address the role of activity restriction in the management of selected women at high risk for adverse pregnancy outcome.

Real time patient safety audits: improving safety every day

A prospective survey of maternal employment and breast-feeding initiation and duration was conducted among 668 Black and 511 White women who delivered their first child in Washington, DC. Ninety-one percent of White women (n = 511) and 80 percent of Black women (n = 668) reported working during pregnancy. Black women who planned to return to work part time vs full time were more likely to breast-feed rather than formula-feed (adjusted odds ratio, 2.3; 95% confidence intervals (CI) = 1.4, 3.7). Using Cox regression, Black women who returned to work had a shorter duration of breast-feeding than those not returning to work (hazard ratio = 0.5 (CI = 0.3, 0.9]. Black and White women returning to professional occupations had a longer duration of breast-feeding compared to women returning to sales or technical positions (hazard ratio for Black women = 2.4 (CI = 1.4, 44); hazard ratio for White women = 1.6 (CI = 1.0, 2.5]. In addition, White women in professional occupations had a longer duration of breast-feeding than women in clerical positions (hazard ratio = 1.7 (CI = 1.1, 2.6]. Until employers in the United States develop a maternity policy which does not discourage breast-feeding, the recommended six months of breast-feeding will be difficult to achieve for most employed women.

Ethnic differences in preterm and very preterm delivery.

OBJECTIVE We sought to determine whether paternal size at birth and during young adulthood influences the birth weight of the offspring. STUDY DESIGN This historic cohort study followed up girls born in Copenhagen during 1959 to 1961. Their pregnancies in 1974 to 1989 were traced through the Danish Population Register, and the Personal Identification Numbers of the fathers of the children were obtained. Paternal birth weight was obtained from midwifery records and adult stature from military draft records. RESULTS Compared with fathers who weighed at least 4 kg at birth, fathers who weighed 3 to 3.99 kg at birth had infants who were 109 gm lighter, and fathers who weighed <3 kg had infants who were 176 gm lighter after adjustment for maternal birth weight and adult stature, smoking, and medical and socioeconomic factors. After adjustment, fathers in the lowest quartile of adult body mass index had infants that were 105 gm lighter than those of fathers in the highest quartile. Both paternal birth weight and adult body mass index exhibited significant trends in association with infant birth weight. CONCLUSION Independently of maternal size, the fathers physical stature, particularly his own size at birth, influences the birth weight of his children.

Reasons for the Rising Cesarean Delivery Rates: 1978–1984

Background: Timely error detection including feedback to clinical staff is a prerequisite for focused improvement in patient safety. Real time auditing, the efficacy of which has been repeatedly demonstrated in industry, has not been used previously to evaluate patient safety. Methods successful at improving quality and safety in industry may provide avenues for improvement in patient safety. Objective: Pilot study to determine the feasibility and utility of real time safety auditing during routine clinical work in an intensive care unit (ICU). Methods: A 36 item patient safety checklist was developed via a modified Delphi technique. The checklist focused on errors associated with delays in care, equipment failure, diagnostic studies, information transfer and non-compliance with hospital policy. Safety audits were performed using the checklist during and after morning work rounds thrice weekly during the 5 week study period from January to March 2003. Results: A total of 338 errors were detected; 27 (75%) of the 36 items on the checklist detected ⩾1 error. Diverse error types were found including unlabeled medication at the bedside (n = 31), ID band missing or in an inappropriate location (n = 70), inappropriate pulse oximeter alarm setting (n = 22), and delay in communication/information transfer that led to a delay in appropriate care (n = 4). Conclusions: Real time safety audits performed during routine work can detect a broad range of errors. Significant safety problems were detected promptly, leading to rapid changes in policy and practice. Staff acceptance was facilitated by fostering a blame free “culture of patient safety” involving clinical personnel in detection of remediable gaps in performance, and limiting the burden of data collection.

Children and managed health care: analysis and recommendations.

Ethnic differences in preterm (less than 37 weeks) and very preterm (less than 33 weeks) delivery were evaluated in a prospective cohort of 28,330 women. Blacks had the highest rate of preterm and very preterm delivery, followed by Mexican-Americans, Asians, and Whites. Adjustment for maternal age, education, marital status, employment, parity, number of previous spontaneous or induced abortions, smoking and drinking during pregnancy, infant sex, and gestational age at initiation of prenatal care resulted in the following odds ratios for preterm delivery: 1.79 (1.55-2.08) for Blacks, 1.40 (1.19-1.63) for Mexican-Americans, 1.40 (1.16-1.69) for Asians, and 1.00 for Whites. The corresponding odds ratios for very preterm delivery were 2.35 (1.72-3.22) for Blacks, 1.31 (0.88-1.94) for Mexican-Americans, 1.10 (0.67-1.83) for Asians, and 1.00 for Whites. Exclusion of cases of premature rupture of membranes, placenta previa, and abruptio placenta did not explain the large ethnic differences. Although Whites and Mexican-Americans had similar birthweight distributions, Mexican-Americans had an increased risk for preterm delivery. Fifty-five per cent of low birthweight babies in Kaiser were preterm and this fraction did not vary substantially by ethnic group.

Prevalence of Drug- Exposed Infants

This study was undertaken to estimate the cesarean delivery rate in United States hospitals and to determine whether the reasons for rise in this rate have changed since the National Institute of Child Health and Human Development Consensus Development Conference on Cesarean Childbirth in 1979. The cesarean delivery rate steadily increased from 9.1% in 1974 to 14.7% in 1978, and to 21.2% in 1984. One-third of the rise in the cesarean rate from 1974–1978 was due to repeat cesareans, and 9% was due to fetal distress. Since 1978, 47% of the rise in the cesarean rate was attributed to repeat cesareans, and 16% to fetal distress. Less of the recent rise in the cesarean rate was due to dystocia and breech presentation. The rate of cesarean delivery among those with a previous cesarean was 96%. Deliveries complicated by fetal distress increased from 1% in 1978 to 6% in 1984. The incidence of breech presentation dropped by 18% (2.8–2.3%), which may indicate an increase in the successful use of external cephalic version. If the number of vaginal deliveries after cesarean increases in the future, then the overall cesarean delivery rate will decrease or stabilize. Additional efforts should be focused on the diagnostic categories of fetal distress and dystocia, because it is likely that the definitions of these complications are changing to include less severe forms.