Teresa Janevic

Neighborhood deprivation and adverse birth outcomes among diverse ethnic groups.

PURPOSE Living in a socioeconomically deprived neighborhood has been associated with an increased risk of adverse birth outcomes. However, variation in the effect of neighborhood deprivation among diverse ethnic groups has not been studied. METHODS Using linked hospital discharge and birth data for 517,994 singleton live births in New York City from 1998 through 2002, we examined the association between neighborhood deprivation, preterm birth (PTB), and term low birthweight (TLBW) (>or=37 weeks and <2500g). Adjusted odds ratios (aORs) for PTB (<32 and 33-36 weeks) and TLBW were estimated using logistic regression. RESULTS The aOR for PTB of less than 32 weeks for the highest quartile of deprivation compared to the lowest was 1.24 (95% confidence limit [CL] = 1.13, 1.36), for PTB 33-36 weeks was 1.06 (95% CL = 1.01, 1.11), and for TLBW was 1.19 (95% CL = 1.11, 1.27). Measures of association varied by ethnicity; aORs of the greatest magnitude for PTB were found among Hispanic Caribbean women (PTB < 32 weeks: aOR = 1.63, 95% CL = 1.27, 2.10; PTB 33-36 weeks: aOR = 1.32, 95% CL = 1.02, 1.70), and for TLBW among African women (aOR = 1.47, 95% CL = 1.02, 2.13). CONCLUSIONS The mechanisms linking neighborhood deprivation to adverse birth outcomes may differ depending on individual ethnicity and/or cultural context and should be investigated in future research.

Maternal Smoking, Preeclampsia, and Infant Health Outcomes in New York City, 1995–2003

A number of previous studies have reported an inverse association between maternal smoking and preeclampsia. Additionally, some have suggested that smokers who develop preeclampsia have worse maternal and fetal outcomes than nonsmokers who develop preeclampsia. The authors examined the relation of smoking to preeclampsia among 674,250 singleton pregnancies in New York City between 1995 and 2003. Although smoking was associated with a reduced risk of preeclampsia overall (adjusted odds ratio = 0.88, 95% confidence interval: 0.82, 0.94), no association was found for preeclampsia superimposed on chronic hypertension (adjusted odds ratio = 1.04, 95% confidence interval: 0.90, 1.21). Furthermore, the apparent protection conferred by maternal smoking was restricted to women aged < or =30 years. Contrary to previous reports, the authors found evidence of a negative interaction between smoking and preeclampsia with respect to preterm delivery and birth weight; smokers who developed preeclampsia had a lower risk of preterm delivery, and a lower adjusted mean difference in birth weight, than would have been expected based on the independent effects of smoking and preeclampsia. These data suggest that smoking is only protective against preeclampsia without pre gestational hypertension, and even then principally among younger women. Additionally, smokers who develop these disorders have no increased risk of adverse birth outcomes relative to nonsmokers who develop the same conditions.

Risk factors for childhood malnutrition in Roma settlements in Serbia

BackgroundChildren living in Roma settlements in Central and Eastern Europe face extreme levels of social exclusion and poverty, but their health status has not been well studied. The objective of this study was to elucidate risk factors for malnutrition in children in Roma settlements in Serbia.MethodsAnthropometric and sociodemographic measures were obtained for 1192 Roma children under five living in Roma settlements from the 2005 Serbia Multiple Indicator Cluster Survey. Multiple logistic regression was used to relate family and child characteristics to the odds of stunting, wasting, and underweight.ResultsThe prevalence of stunting, wasting, and underweight was 20.1%, 4.3%, and 8.0%, respectively. Nearly all of the children studied fell into the lowest quintile of wealth for the overall population of Serbia. Children in the lowest quintile of wealth were four times more likely to be stunted compared to those in the highest quintile, followed by those in the second lowest quintile (AOR = 2.1) and lastly by those in the middle quintile (AOR = 1.6). Children who were ever left in the care of an older child were almost twice as likely to stunted as those were not. Children living in urban settlements showed a clear disadvantage with close to three times the likelihood of being wasted compared to those living in rural areas. There was a suggestion that maternal, but not paternal, education was associated with stunting, and maternal literacy was significantly associated with wasting. Whether children were ever breastfed, immunized or had diarrhoeal episodes in the past two weeks did not show strong correlations to children malnutrition status in this Roma population.ConclusionsThere exists a gradient relationship between household wealth and stunting even within impoverished settlements, indicating that among poor and marginalized populations socioeconomic inequities in child health should be addressed. Other areas on which to focus future research and public health intervention include maternal literacy, child endangerment practices, and urban settlements.

Mode of delivery and neonatal outcomes in preterm, small-for-gestational-age newborns.

OBJECTIVE: To compare neonatal outcomes by method of delivery in preterm (34 weeks of gestation or prior), small-for-gestational-age (SGA) newborns in a large diverse cohort. METHODS: Birth data for 1995–2003 from New York City were linked to hospital discharge data. Data were limited to singleton, liveborn, vertex neonates delivered between 25 and 34 weeks of gestation. Births complicated by known congenital anomalies and birth weight less than 500 g were excluded. Small for gestational age was used as a surrogate for intrauterine growth restriction. Associations between method of delivery and neonatal morbidities were estimated using logistic regression. RESULTS: Two thousand eight hundred eighty-five SGA neonates meeting study criteria were identified; 42.1% were delivered vaginally, and 57.9% were delivered by cesarean. There was no significant difference in intraventricular hemorrhage, subdural hemorrhage, seizure, or sepsis between the cesarean delivery and vaginal delivery groups. Cesarean delivery compared with vaginal delivery was associated with increased odds of respiratory distress syndrome. The increased odds persisted after controlling for maternal age, parity, ethnicity, education, primary payer, prepregnancy weight, gestational age at delivery, diabetes, and hypertension. CONCLUSION: Cesarean delivery was not associated with improved neonatal outcomes in preterm SGA newborns and was associated with an increased risk of respiratory distress syndrome. LEVEL OF EVIDENCE: II

Mode of delivery in nulliparous women and neonatal intracranial injury.

OBJECTIVE: To compare neonatal neurologic complication rates of cesarean deliveries, forceps-assisted vaginal deliveries, and vacuum-assisted vaginal deliveries. METHODS: Data on singleton live births at 34 weeks or greater gestation born to nulliparous women from 1995 to 2003 in New York City were linked to hospital discharge data. Any diagnosis of neonatal subdural hemorrhage, intraventricular hemorrhage, seizures, scalp laceration or cephalohematoma, fracture, facial nerve palsy, brachial plexus injury, or 5-minute Apgar score of less than 7 was considered significant. Multivariable logistic regression was used to estimate associations between delivery mode and these neonatal morbidities. RESULTS: Forceps-assisted vaginal deliveries were associated with significantly fewer seizures and 5-minute Apgar scores less than 7 compared with vacuum-assisted vaginal deliveries and cesarean deliveries. Cesarean deliveries were linked to less subdural hemorrhages compared with forceps-assisted vaginal deliveries or vacuum-assisted vaginal deliveries. When seizure, intraventricular hemorrhage, and subdural hemorrhage were examined collectively to best predict neurologic outcome, forceps-assisted vaginal deliveries had an overall reduced risk compared with both vacuum-assisted vaginal deliveries (odds ratio [OR] 0.60, 95% confidence interval [CI] 0.40–0.90) and cesarean deliveries (OR 0.68, 95% CI 0.48–0.97). The number needed to treat to prevent one case of severe neurologic morbidity is 509 for forceps-assisted vaginal deliveries compared with vacuum-assisted vaginal deliveries and 559 for forceps-assisted vaginal deliveries compared with cesarean deliveries. CONCLUSION: Compared with vacuum-assisted vaginal delivery or cesarean delivery, a forceps-assisted vaginal delivery is associated with a reduced risk of adverse neonatal neurologic outcomes. LEVEL OF EVIDENCE: II

Maternal education and adverse birth outcomes among immigrant women to the United States from Eastern Europe: A test of the healthy migrant hypothesis

Immigrant women to the U.S. often have more favorable birth outcomes than their native-born counterparts, including lower rates of preterm birth and low birth weight, a phenomenon commonly attributed to a healthy migrant effect. However, this effect varies by ethnicity and country of origin. No previous study has examined birth outcomes among immigrants from the post-Communist countries of Eastern Europe, a group which includes both economic migrants and conflict refugees. Using data on 253,363 singletons births from New York City during 1995-2003 we examined the risk of preterm birth (PTB) (<37 weeks) or delivering a term small-for-gestational-age (SGA) infant among immigrants from Russia and Ukraine (RU), Poland, and former Yugoslavia Republics (FYR) relative to US-born non-Hispanic whites (NHW). Women in all three Eastern European groups had significantly later entry into prenatal care, were more likely to be Medicaid recipients, and had lower educational attainment than US-born NHW. In binomial regression analyses adjusting for age, education, parity, and pre-pregnancy weight, women from RU and FYR had lower risk of PTB than US-born NHW, whereas women from Poland had similar risk. Lower SGA risk was found among women from Poland and FYR, but not RU. When stratified by education, women with <12 years of education from all Eastern European groups had a reduced risk of PTB relative to US-born NHW. An educational gradient in PTB and SGA risk was less pronounced in all Eastern European groups compared to US-born NHW. The healthy migrant effect is present among immigrants from Eastern Europe to the U.S., especially among women with less education and those from the former Yugoslavia, a group that included many conflict refugees.

Maternal ethnic ancestry and adverse perinatal outcomes in New York City.

OBJECTIVE We sought to examine the association between narrowly defined subsets of maternal ethnicity and birth outcomes. STUDY DESIGN We analyzed 1995-2003 New York City birth certificates linked to hospital discharge data for 949,210 singleton births to examine the multivariable associations between maternal ethnicity and preterm birth, subsets of spontaneous and medically indicated preterm birth, term small for gestational age, and term birthweight. RESULTS Compared with non-Hispanic whites, Puerto Ricans had an elevated odds ratio (1.9; 95% confidence interval, 1.9-2.0) for delivering at 32-36 weeks (adjusted for nativity, maternal age, parity, education, tobacco use, prepregnancy weight, and birth year). We found an excess of adverse outcomes among most Latino groups. Outcomes also varied within regions, with North African infants nearly 100 g (adjusted) heavier than sub-Saharan African infants. CONCLUSION The considerable heterogeneity in risk of adverse perinatal outcomes is obscured in broad categorizations of maternal race/ethnicity and may help to formulate etiologic hypotheses.

Neighbourhood food environment and gestational diabetes in New York City

The association between neighbourhood characteristics and gestational diabetes has not been examined previously. We investigated the relationship between the number of healthy food outlets (supermarkets; fruit/vegetable and natural food stores), and unhealthy food outlets (fast food; pizza; bodegas; bakeries; convenience, candy/nut and meat stores) in census tract of residence, and gestational diabetes in New York City. Gestational diabetes, census tract and individual-level covariates were ascertained from linked birth-hospital data for 210 926 singleton births from 2001 to 2002 and linked to commercial data on retail food outlets. Adjusted odds ratios (aOR) were estimated using a multilevel logistic model. No association between food environment measures and gestational diabetes was found, with aORs ranging from 0.95 to 1.04. However, an increased odds of pre-pregnancy weight >200 lbs for women living in a given neighbourhood with no healthy food outlets [aOR = 1.14, 95% CI 1.07, 1.21] or only one healthy food place [aOR = 1.10, 95% CI 1.04, 1.18] relative to two or more healthy food outlets was found. Due to probable misclassification of neighbourhood food environment and pre-pregnancy obesity results are likely to be biased towards the null. Future research, including validity studies, on the neighbourhood food environment, obesity during pregnancy and gestational diabetes is warranted.

The Effect of Hurricane Sandy on Cardiovascular Events in New Jersey

Background Hurricane Sandy made landfall in New Jersey (NJ) on October 29, 2012. We studied the impact of this extreme weather event on the incidence of, and 30‐day mortality from, cardiovascular (CV) events (CVEs), including myocardial infarctions (MI) and strokes, in NJ. Methods and Results Data were obtained from the MI data acquisition system (MIDAS), a database of all inpatient hospital discharges with CV diagnoses in NJ, including death certificates. Patients were grouped by their county of residence, and each county was categorized as either high‐ (41.5% of the NJ population) or low‐impact area based on data from the Federal Emergency Management Agency and other sources. We utilized Poisson regression comparing the 2 weeks following Sandy landfall with the same weeks from the 5 previous years. In addition, we used CVE data from the 2 weeks previous in each year as to adjust for yearly changes. In the high‐impact area, MI incidence increased by 22%, compared to previous years (attributable rate ratio [ARR], 1.22; 95% confidence interval [CI], 1.16, 1.28), with a 31% increase in 30‐day mortality (ARR, 1.31; 95% CI, 1.22, 1.41). The incidence of stroke increased by 7% (ARR, 1.07; 95% CI, 1.03, 1.11), with no significant change in 30‐day stroke mortality. There were no changes in incidence or 30‐day mortality of MI or stroke in the low‐impact area. Conclusion In the 2 weeks following Hurricane Sandy, there were increases in the incidence of, and 30‐day mortality from, MI and in the incidence of stroke.

Effects of work and life stress on semen quality

OBJECTIVE To evaluate associations between work-related stress, stressful life events, and perceived stress and semen quality. DESIGN Cross-sectional analysis. SETTING Northern California. PATIENT(S) 193 men from the Child Health and Development Studies evaluated between 2005-2008. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Measures of stress including job strain, perceived stress, and stressful life events; outcome measures of sperm concentration, percentage of motile sperm, and percentage of morphologically normal sperm. RESULT(S) We found an inverse association between perceived stress score and sperm concentration (estimated coefficient b=-0.09×10(3)/mL; 95% confidence interval [CI]=-0.18, -0.01), motility (b=-0.39; 95% CI=-0.79, 0.01), and morphology (b=-0.14; 95% CI, -0.25, -0.04) in covariate-adjusted linear regression analyses. Men who experienced two or more stressful life events in the past year compared with no stressful events had a lower percentage of motile sperm (b=-8.22; 95% CI, -14.31, -2.13) and a lower percentage of morphologically normal sperm (b=-1.66; 95% CI, -3.35, 0.03) but a similar sperm concentration. Job strain was not associated with semen parameters. CONCLUSION(S) In this first study to examine all three domains of stress, perceived stress and stressful life events but not work-related stress were associated with semen quality.