Pierre Buekens

Psychosocial Factors and Preterm Birth Among African American and White Women in Central North Carolina

Objectives. We assessed associations between psychosocial factors and preterm birth, stratified by race in a prospective cohort study.Methods. We surveyed 1898 women who used university and public health prenatal clinics regarding various psychosocial factors.Results. African Americans were at higher risk of preterm birth if they used distancing from problems as a coping mechanism or reported racial discrimination. Whites were at higher risk if they had high counts of negative life events or were not living with a partner. The association of pregnancy-related anxiety with preterm birth weakened when medical comorbidities were taken into account. No association with preterm birth was found for depression, general social support, or church attendance.Conclusions. Some associations between psychosocial variables and preterm birth differed by race.

Birth outcomes of immigrant women in the United States, France, and Belgium.

Objectives: To compare maternal characteristics and birth outcomes of Mexico-born and native-born mothers in the United States and those of North African mothers living in France and Belgium to French and Belgian nationals. Methods: We examined information from single live birth certificates for 285,371 Mexico-born and 3,131,632 U.S.-born mothers (including 2,537,264 U.S.-born White mothers) in the United States, 4,623 North African and 103,345 Belgian mothers in Belgium, and a French national random sample consisting of 632 North African and 11,185 French mothers. The outcomes were mean birthweight, low birthweight, and preterm births. Differences between native/nationals and foreign-born mothers in each country were assessed in bivariate and multivariate analyses controlling for maternal risk factors. Results: The adjusted odds for low birthweight were lower for immigrants than native/nationals by 32% in the United States, by 32% in Belgium, and by 30% in France. The adjusted odds for preterm births were lower for immigrants compared with native/nationals by 11% in the United States and by 23% in Belgium. In France, the odds for preterm births were comparable for immigrants and naturalized mothers. Infants of immigrant mothers also had higher mean birthweights in all three countries. Conclusion: Despite their disadvantaged status, Mexico-born and North African-born women residing in the United States, France, and Belgium show good birth outcomes. These cannot be explained solely by traditional risk factors. Protective factors and selective migration may offer further clues.

Barriers to prenatal care in Europe.

BACKGROUND In Europe, it is sometimes assumed that few barriers to prenatal care exist because extensive programs of health insurance and initiatives to promote participation in prenatal care have been established for many decades. METHODS A case-control study was performed in ten European countries (Austria, Denmark, Germany, Greece, Hungary, Ireland, Italy, Portugal, Spain, and Sweden). Postpartum interviews were conducted between 1995 and 1996. A total of 1283 women with inadequate prenatal care (i.e., with 0, 1, or 2 prenatal care visits or a first prenatal care visit after 15 completed weeks of pregnancy) and 1280 controls with adequate prenatal care were included in the analysis combining data from the ten countries. RESULTS Based on combined data of the ten countries, lack of health insurance was found to be an important risk factor for inadequate prenatal care (crude odds ratio [OR] at 95% confidence interval [CI]: 30.1 [20.1-47.1]). Women with inadequate prenatal care were more likely to be aged < 20 years (16.4% vs 4.8%) and with higher parity (number of children previously borne) than controls. They were more likely to be foreign nationals, unmarried, and with an unplanned pregnancy. Women with inadequate care were also more likely to have less education and no regular income. They had more difficulties dealing with health services organization and child care. Cultural and financial barriers were present, but after adjusting for confounders by logistic regression, perceived financial difficulty was not a significant factor for inadequate prenatal care (adjusted OR [95% CI]: 0.7 [0.4-1.3]). CONCLUSIONS Personal, socioeconomic, organizational, and cultural barriers to prenatal care exist in Europe.

The Maternal and Newborn Health Registry Study of the Global Network for Women's and Children's Health Research

To implement a vital statistics registry system to register pregnant women and document birth outcomes in the Global Network for Womens and Childrens Health Research sites in Asia, Africa, and Latin America.

Disparity in prenatal care in Europe

Abstract Objective: The purpose of the study was to compare prenatal care attendance in European Union countries, Hungary and Norway. Study Design: We analysed live births or deliveries from national registers in five countries, national surveys in five countries, and regional register or surveys in three countries. Results: The frequency of no prenatal care was lower than 0.5% in 10 countries, 0.9% in Hungary, 2.1% in Greece and 2.6% in Portugal. Late prenatal care varied from 3.1% in Finland to 29.2% in Ireland. Late care among women with parity 4 and more varied from 7.7% in Finland to 41.5% in Hungary. Among women under 20 years old, late care varied from 11.8% in Finland to 39.5% in Portugal. The median number of prenatal visits varied from seven in Greece to 14 in Finland. Conclusion: Prenatal care attendance varies widely among European countries. Late attendance is frequent in many countries.

Is estimating maternal mortality useful

In this issue, Hill, AbouZahr &Wardlaw (1) present new estimates of maternal mortality for 1995. They have carefully adjusted the data for underreporting, and used statistical models in countries lacking relevant data. They have obtained a global estimate ranging from some 303 000 to 822 000 maternal deaths. This very large range is mostly the consequence of the limited quality of available data. In only 17 countries were the data based on Reproductive Age Mortality Study (RAMOS), one of the bestmethods tomeasurematernal mortality. Many country-specific estimates presented by the authors are based on assumptions that are generally conservative. For example, they mainly used an adjustment factor of 1.5 to estimate maternal mortality ratios in 48 countries with a good registration system, including the USA. However, the number of maternal deaths in the USA could be more than twice as high as the reported number (2). The estimates presented here might thus be lower than the actual values. Maternal mortality remains an extremely important problem, and might be worse than we suspect. It is not impossible that ne million maternal deaths occurred in the world in 1995. The authors carefully discuss the limitations of their data, and emphasize that no valid conclusions can be drawn from them about trends: the data are too imprecise to provide a basis for such analyses, and the method used is slightly different from the one used to make the estimates for 1990. Interestingly enough, the relative imprecision of the estimates is of similar magnitude in industrialized and in developing countries. For example, the point estimate of maternal mortality ratio for Europe is 28 per 100 000 live births, with a lower uncertainty bound of 18 per 100 000 live births. For Africa, the point estimate of maternal mortality ratio is 1006 per 100 000 live births, with a lower uncertainty bound of 544 per 100 000 live births. The lower bound in Europe is thus 36% lower than the point estimate, while in Africa it is 46% lower. Few programmes would be expected to have a measurable shortterm impact that is larger than the imprecision of the estimates. These data, once again, demonstrate that maternal mortality ratios are not useful for the monitoring or evaluation of Safe Motherhood programmes (3). Thus the recommendation to use process indicators (such as caesarean section rates) for monitoring and evaluation purposes is well-founded. Despite these limitations, estimating maternal mortality is useful. Disparities between the ratios are so huge that even imprecise data allow us to see their persistence. In 1995 the maternal mortality ratio was almost 400 times higher in Rwanda (2318 per 100 000 live births) than in Finland (6 per 100 000 live births). Interventions that can reduce this mortality are available, and include better access to emergency obstetrical care (4). Our objective must thus be to achieve what is known to be possible: the large and rapid decrease of maternal mortality. The estimates presented by Hill and collaborators show that this is not happening. To document such a tragedy is useful, supports our advocacy efforts, and shows the urgency of the issue. Every effort should be made to have high quality data on maternal mortality. Industrialized countries could use enhanced registration systems on a regular basis, and RAMOS at least every 10 years. Enhanced registration should include routine linkage of death and birth certificates. In developing countries, high quality data could be derived from a variety of methods, including RAMOS studies and new census questions (5). Measuring maternal mortality is the only way to ensure that its reduction remains a top priority. n

Cord C-peptide and insulin-like growth factor-I, birth weight, and placenta weight among North African and Belgian neonates.

OBJECTIVE Despite their low socioeconomic status, infants of North African immigrants have been reported to have high birth weights in Belgium. The aim of the study was to further explore potential mechanisms explaining this high birth weight. STUDY DESIGN Venous umbilical cord blood samples and perinatal characteristics of live-born infants from mothers of North African and Belgian nationality were collected in 1997 through 1998 at the University Hospital La Citadelle, Liège, Belgium. RESULTS The median connecting peptide (C-peptide) concentration was significantly higher among North African than Belgian neonates (0.125 vs 0.110 pmol/mL, P=.04). However, the median insulin-like growth factor-I concentrations among North African and Belgian newborn infants were, respectively, 74.0 and 69.6 ng/mL (P=.45). Nationality remained significantly associated with C-peptide after adjusting for age and parity. C-peptide, insulin-like growth factor-I correlated positively with birth weight and remained significant factors for birth weight after adjusting for confounders in multiple regression. CONCLUSION These results suggest a link between higher C-peptide levels and birth weights among North African neonates in Belgium.

A Comparison of Risk Factors for Twin Preterm Birth in the United States Between 1981-82 and 1996-97

Objective: This paper examines risk factors for twin preterm birth in 1981–82 and 1996–97 in the United States in order to see if they have changed over time. Methods: We studied all U.S. twin births for the years examined (N = 346,567). Since the gestational age distributions for twins differs from singletons, the risk of preterm birth was examined at <33, 33–34, and 35–36 weeks. Logistic regression was used to examine the contributions of sociodemographic and obstetric factors at each period. Results: While the <33 week twin preterm rate rose 7% from 1981–82 to 1996–97, the 33–34-week rate rose 31%, and the 35–36-week rate rose 51%. Women with less education, teenagers, unmarried women, primiparas, and blacks were more likely to deliver preterm across all three preterm birth levels. However, the effect of these low socioeconomic status markers diminished over the study period. Additionally, the odds of preterm birth among blacks increased with earlier gestational ages. Women who had intensive prenatal care utilization as compared with less than adequate utilization were more likely to deliver preterm (35–36 weeks) in 1996–97 (odds ratio (OR) = 2.05) compared with 1981–82 (OR = 1.44). Smaller increases were noted for <33 and 33–34 weeks. Conclusions: Obstetric factors appear to be playing a greater role in the rise of twin preterm births at 35–36 weeks gestation. Temporal sociodemographic changes do not explain the rise in the preterm rate. Changing clinical practices may be having unintended consequences on the public health goals of reducing preterm and low birthweight rates in the United States.

Does awareness of rates of obstetric interventions change practice

Dr A E Fletcher, Department of Epidemiology and Population Sciences, London School ofHygiene and Tropical Medicine, London WC1E 7HT. atenolol, but in an observational study we cannot discount the possibility of confounding factors. Our model adjusted for the most obvious of these (age and smoking), but there may be other unidentified factors. The strength of experimental studies is that randomisation removes selection bias. In the Medical Research Councils trial the relative risk of dying from cancer for men receiving atenolol was 1 9 compared with placebo (1-2 to 2 8) and 1-4 (0 9 to 2 2) compared with diuretic. In our study the 95% confidence intervals of the relative risks for all cancers and for lung cancer excluded a twofold excess risk from atenolol. We cannot exclude risks lower than this.

Effects of essential newborn care training on fresh stillbirths and early neonatal deaths by maternal education.

Background: Infants of women with lower education levels are at higher risk for perinatal mortality. Objectives: We explored the impact of training birth attendants and pregnant women in the Essential Newborn Care (ENC) Program on fresh stillbirths (FSBs) and early (7-day) neonatal deaths (END) by maternal education level in developing countries. Methods: A train-the-trainer model was used with local instructors in rural communities in six countries (Argentina, Democratic Republic of the Congo, Guatemala, India, Pakistan, and Zambia). Data were collected using a pre-/post-active baseline controlled study design. Results: A total of 57,643 infants/mothers were enrolled. The follow-up rate at 7 days of age was 99.2%. The risk for FSB and END was higher for mothers with 0-7 years of education than for those with ≥8 years of education during both the pre- and post-ENC periods in unadjusted models and in models adjusted for confounding. The effect of ENC differed as a function of maternal education for FSB (interaction p = 0.041) without evidence that the effect of ENC differed as a function of maternal education for END. The model-based estimate of FSB risk was reduced among mothers with 0-7 years of education (19.7/1,000 live births pre-ENC, CI: 16.3, 23.0 vs. 12.2/1,000 live births post-ENC, CI: 16.3, 23.0, p < 0.001), but was not significantly different for mothers with ≥8 years of education, respectively. Conclusion: A low level of maternal education was associated with higher risk for FSB and END. ENC training was more effective in reducing FSB among mothers with low education levels.