Risk Factors for Low Birthweight in Zimbabwean Women: A Secondary Data Analysis

Background

Low birth weight (LBW) remains the main cause of mortality and morbidity in infants, and a problem in the care of pregnant women world-wide particularly in developing countries. The purpose of this study was to describe the socio-demographic, nutritional, reproductive, medical and obstetrical risk factors for delivering a live LBW infant at Harare Maternity Hospital, Zimbabwe.

Methods

A secondary data analysis from data obtained through a questionnaire and delivery records was conducted. Linear regression models with a complimentary log-log link function were used to estimate the relative risks for all LBW, term LBW and preterm LBW.

Results

The frequency of LBW was 16.7%. Lack of prenatal care (adjusted relative risk [ARR] 1.69, 95% CI 1.44, 1.98), mother’s mid-arm circumference below 28.5 cm, (ARR 1.35, 95% CI 1.19, 1.54) and rural residence (ARR 1.22, 95% CI 1.04, 1.40) increased the risk of LBW. Eclampsia, anemia, and ante-partum hemorrhage, were associated with LBW (ARR 2.64, 95% CI 1.30, 5.35; ARR = 2.63, 95% CI 1.16, 5.97; and ARR = 2.39, 95% CI 1.55, 3.68), respectively. Malaria increased the risk of LBW (ARR = 1.89, 95% CI 1.21, 2.96). Prenatal care, infant sex, anemia, antepartum hemorrhage, premature rapture of membranes and preterm labor were associated with the three LBW categories. History of abortion or stillbirth, history of LBW, malaria, eclampsia, and placenta Previa, were associated with all LBW and preterm LBW, while pregnancy induced hypertension, and number of children alive were associated with all LBW and term LBW.

Conclusions

LBW frequency remains high and is associated with nutritive, reproductive, medical and obstetrical factors. Preterm LBW and term LBW have similar and also different risk factors. Understanding the role of different risk factors in these different LBW categories is important if the goal is to reduce LBW frequency, and its complications, in Zimbabwe.     

The Growing Trend of Moderate Preterm Births: An Ecological Study in One Region of Brazil

Background

Preterm birth is a serious public health problem, as it is linked to high rates of neonatal and child morbidity and mortality, with Brazil listed among the countries with the ten highest numbers of premature births. Nonetheless, knowledge is scarce regarding prematurity and associated factors in mid-sized cities. The objective of this study was to analyze the trend of preterm births and associated factors in a municipality located in the state of Paraná, Brazil.

Methods

This was an ecological time series study of births recorded into the Live Birth Information System for residents of Maringá, Paraná, Brazil, between 2000 and 2013. The polynomial regression model was used for trend analysis of preterm birth, characteristics of the mother, gestation and delivery, and newborn. The association with preterm birth was analyzed using odds ratio (OR).

Results

A total of 61,634 live births were analyzed, of which 5,632 were preterm births. Prematurity increased from 7.9% in 2000 to 11.2% in 2013 –an average increase of 0.54% per year (r² = 0.93)–with a growing share of moderate preterm births (32 to <37 weeks), which rose from 7.0% in 2000 to 9.7% in 2013. Between 2011 and 2013, multiple pregnancy (OR = 16.64; CI = 13.24–20.92), inadequate number of prenatal visits (OR = 2.81; CI = 2.51–3.15), Apgar score below 7 at 1 (OR = 4.07; CI = 3.55–4.67) and 5 minutes (OR = 10.88; CI = 7.71–15.36), low birth weight (OR = 38.75; CI = 33.72–44.55) and congenital malformations (OR = 3.18; CI = 2.14–4.74) were associated with preterm birth. A growing trend was observed for multiple pregnancies, with an average annual increase of 0.32% (r² = 0.90), as well as for C-section birth (2.38% yearly increase). Of all newborn characteristics, Apgar score below 7 at 5 minutes (-0.19% per year) and low birth weight (-1.43%) decreased, whereas congenital malformations rose (0.20% per year).

Conclusions

Efforts are required to prevent premature delivery, particularly during the moderate period, as well as greater care during the prenatal period towards expectant mothers bearing multiple pregnancies, birth defects, in addition to reducing C-section birth as it may be linked to preterm birth.     

Prenatal Care in Combination with Maternal Educational Level Has a Synergetic Effect on the Risk of Neonatal Low Birth Weight: New Findings in a Retrospective Cohort Study in Kunshan City,China

Objectives

To investigate the dose-response relationship and synergetic effect of the maternal educational level and two measures of prenatal care on neonatal low birth weight (LBW) risk.

Methods

Data were derived from the Perinatal Health Care Surveillance System (PHCSS) from January 2001 to September 2009 in Kunshan City, Jiangsu province, eastern China, which included data on 31412 women with a normal birth weight delivery and 640 women with a LBW delivery. Logistic modelling was performed to estimate the association including the joint effects with odds ratio (OR) and 95% confidence interval (CI) between the prenatal care measures and LBW risk after adjusting for the potential confounders. The dose-response relationship between the number of prenatal care visits and the risk of LBW was investigated by modeling the quantitative exposure with restricted cubic splines (RCS).

Results

There was a significant synergetic effect on the LBW risk between maternal educational attainment and the number of prenatal care visits (χ² = 4.98, P = 0.0257), whereas no significant maternal educational attainment interaction was found with the week of initiation of prenatal care after adjusting for relevant confounding factors (χ² = 2.04, P = 0.1530), and the LBW risk displayed a ‘U-shape’ curve tendency among the different number of prenatal care visits (P for nonlinearity = 0.0002) using RCS. In particular, the ORs were approaching the curve’s bottom when the women had 9 or 10 prenatal care visits. Comparing with 5 prenatal care visits, the ORs and 95%CI of LBW risk for 7, 9, 11 and ≥13 visits were 0.92 (0.82–1.03), 0.50 (0.38–0.66), 0.62 (0.47–0.82), and 0.99 (0.61–1.60), respectively.

Conclusions

Our findings suggest that appropriate prenatal care, in combination with a higher maternal educational level, can produce a protective interaction effect on LBW risk. Reasonable health resource assignment for different social statuses should be taken into account by policy-makers in developing countries.     

Contextual Risk Factors for Low Birth Weight: A Multilevel Analysis

Background

Low birth weight (LBW) remains to be a leading cause of neonatal death and a major contributor to infant and under-five mortality. Its prevalence has not declined in the last decade in sub-Saharan Africa (SSA) and Asia. Some individual level factors have been identified as risk factors for LBW but knowledge is limited on contextual risk factors for LBW especially in SSA.

Methods

Contextual risk factors for LBW in Ghana were identified by performing multivariable multilevel logistic regression analysis of 6,900 mothers dwelling in 412 communities that participated in the 2003 and 2008 Demographic and Health Surveys in Ghana.

Results

Contextual-level factors were significantly associated with LBW: Being a rural dweller increased the likelihood of having a LBW infant by 43% (OR 1.43; 95% CI 1.01–2.01; P-value <0.05) while living in poverty-concentrated communities increased the risk of having a LBW infant twofold (OR 2.16; 95% CI 1.29–3.61; P-value <0.01). In neighbourhoods with a high coverage of safe water supply the odds of having a LBW infant reduced by 28% (OR 0.74; 95% CI 0.57–0.96; P-value <0.05).

Conclusion

This study showed contextual risk factors to have independent effects on the prevalence of LBW infants. Being a rural dweller, living in a community with a high concentration of poverty and a low coverage of safe water supply were found to increase the prevalence of LBW infants. Implementing appropriate community-based intervention programmes will likely reduce the occurrence of LBW infants.     

Antenatal Corticosteroids for Reducing Adverse Maternal and Child Outcomes in Special Populations of Women at Risk of Imminent Preterm Birth: A Systematic Review and Meta-Analysis

Background

This study synthesizes available evidence on antenatal corticosteroids (ACS) use among special subgroups of women at risk of imminent preterm birth, including those (1) with pregestational and gestational diabetes mellitus, (2) undergoing elective caesarean section (CS) in late preterm (34 to<37 weeks), (3) with chorioamnionitis, and (4) with growth-restricted fetuses.

Methods

A systematic search of MEDLINE, EMBASE, CINAHL, Cochrane Library, POPLINE, and World Health Organization Regional Databases was conducted for all comparative studies. Two reviewers independently determined study eligibility, extracted data, and assessed study quality. Pooled mean differences and odds ratios with 95% confidence intervals were estimated from available data, based on fixed- and random-effects models, as appropriate.

Results

No eligible studies were identified for ACS use in diabetic pregnant women or those undergoing elective CS at late preterm. Nine studies each on ACS use in women with chorioamnionitis and in women with fetal growth restriction met inclusion criteria; eight studies were separately included in the meta-analyses for the two subpopulations. For ACS administration in women with chorioamnionitis, pooled analyses showed reductions in neonatal mortality (OR: 0.49, 95% CI: 0.34–0.73), respiratory distress syndrome (OR: 0.58, 95% CI: 0.44–0.76), intraventricular haemorrhage (OR: 0.41, 95% CI: 0.24–0.69), and severe intraventricular haemorrhage (OR: 0.40, 95% CI: 0.24–0.69). Maternal and long-term newborn outcomes were not reported. Effects of ACS use were inconclusive for cases with fetal growth restriction.

Conclusion

Direct evidence on the effectiveness and safety of ACS is lacking for diabetic pregnant women at risk of preterm birth and those undergoing elective late-preterm CS, though this does not necessarily recommend against their use in diabetic women. While evidence remains inconclusive for women with growth-restricted preterm neonates, ACS appears to benefit preterm neonates delivered by women with chorioamnionitis. High-quality studies on maternal and long-term child outcomes in more diverse settings are needed to establish the balance of potential harms versus benefits in using ACS for these understudied subgroups.     

Plasmodium vivax Malaria in Pregnant Women in the Brazilian Amazon and the Risk Factors Associated with Prematurity and Low Birth Weight: A Descriptive Study

Introduction

Plasmodium vivax is the most prevalent malaria species in the American region. Brazil accounts for the higher number of the malaria cases reported in pregnant women in the Americas. This study aims to describe the characteristics of pregnant women with malaria in an endemic area of the Brazilian Amazon and the risk factors associated with prematurity and low birth weight (LBW).

Methods/Principal Findings

Between December 2005 and March 2008, 503 pregnant women with malaria that attended a tertiary health centre were enrolled and followed up until delivery and reported a total of 1016 malaria episodes. More than half of study women (54%) were between 20–29 years old, and almost a third were adolescents. The prevalence of anaemia at enrolment was 59%. Most women (286/503) reported more than one malaria episode and most malaria episodes (84.5%, 846/1001) were due to P. vivax infection. Among women with only P. vivax malaria, the risk of preterm birth and low birth weight decreased in multigravidae (OR, 0.36 [95% CI, 0.16–0.82]; p = 0.015 and OR 0.24 [95% CI, 0.10–0.58]; p = 0.001, respectively). The risk of preterm birth decreased with higher maternal age (OR 0.43 [95% CI, 0.19–0.95]; p = 0.037) and among those women who reported higher antenatal care (ANC) attendance (OR, 0.32 [95% CI, 0.15–0.70]; p = 0.005).

Conclusion

This study shows that P. vivax is the prevailing species among pregnant women with malaria in the region and shows that vivax clinical malaria may represent harmful consequences for the health of the mother and their offsprings particularly on specific groups such as adolescents, primigravidae and those women with lower ANC attendance.     

Variations in Multiple Birth Rates and Impact on Perinatal Outcomes in Europe

Objective

Infants from multiple pregnancies have higher rates of preterm birth, stillbirth and neonatal death and differences in multiple birth rates (MBR) exist between countries. We aimed to describe differences in MBR in Europe and to investigate the impact of these differences on adverse perinatal outcomes at a population level.

Methods

We used national aggregate birth data on multiple pregnancies, maternal age, gestational age (GA), stillbirth and neonatal death collected in the Euro-Peristat project (29 countries in 2010, N = 5 074 643 births). We also used European Society of Human Reproduction and Embryology (ESHRE) data on assisted conception and single embryo transfer (SET). The impact of MBR on outcomes was studied using meta-analysis techniques with random-effects models to derive pooled risk ratios (pRR) overall and for four groups of country defined by their MBR. We computed population attributable risks (PAR) for these groups.

Results

In 2010, the average MBR was 16.8 per 1000 women giving birth, ranging from 9.1 (Romania) to 26.5 (Cyprus). Compared to singletons, multiples had a nine-fold increased risk (pRR 9.4, 95% Cl 9.1–9.8) of preterm birth (<37 weeks GA), an almost 12-fold increased risk (pRR 11.7, 95% CI 11.0–12.4) of very preterm birth (<32 weeks GA). Pooled RR were 2.4 (95% Cl 1.5–3.6) for fetal mortality at or after 28 weeks GA and 7.0 (95% Cl 6.1–8.0) for neonatal mortality. PAR of neonatal death and very preterm birth were higher in countries with high MBR compared to low MBR (17.1% (95% CI 13.8–20.2) versus 9.8% (95% Cl 9.6–11.0) for neonatal death and 29.6% (96% CI 28.5–30.6) versus 17.5% (95% CI 15.7–18.3) for very preterm births, respectively).

Conclusions

Wide variations in MBR and their impact on population outcomes imply that efforts by countries to reduce MBR could improve perinatal outcomes, enabling better long-term child health.     

Preterm Birth and Childhood Wheezing Disorders: A Systematic Review and Meta-Analysis

Background

Accumulating evidence implicates early life factors in the aetiology of non-communicable diseases, including asthma/wheezing disorders. We undertook a systematic review investigating risks of asthma/wheezing disorders in children born preterm, including the increasing numbers who, as a result of advances in neonatal care, now survive very preterm birth.

Methods and Findings

Two reviewers independently searched seven online databases for contemporaneous (1 January 1995–23 September 2013) epidemiological studies investigating the association between preterm birth and asthma/wheezing disorders. Additional studies were identified through reference and citation searches, and contacting international experts. Quality appraisal was undertaken using the Effective Public Health Practice Project instrument. We pooled unadjusted and adjusted effect estimates using random-effects meta-analysis, investigated “dose–response” associations, and undertook subgroup, sensitivity, and meta-regression analyses to assess the robustness of associations. We identified 42 eligible studies from six continents. Twelve were excluded for population overlap, leaving 30 unique studies involving 1,543,639 children. Preterm birth was associated with an increased risk of wheezing disorders in unadjusted (13.7% versus 8.3%; odds ratio [OR] 1.71, 95% CI 1.57–1.87; 26 studies including 1,500,916 children) and adjusted analyses (OR 1.46, 95% CI 1.29–1.65; 17 studies including 874,710 children). The risk was particularly high among children born very preterm (<32 wk gestation; unadjusted: OR 3.00, 95% CI 2.61–3.44; adjusted: OR 2.81, 95% CI 2.55–3.12). Findings were most pronounced for studies with low risk of bias and were consistent across sensitivity analyses. The estimated population-attributable risk of preterm birth for childhood wheezing disorders was ≥3.1%.Key limitations related to the paucity of data from low- and middle-income countries, and risk of residual confounding.

Conclusions

There is compelling evidence that preterm birth—particularly very preterm birth—increases the risk of asthma. Given the projected global increases in children surviving preterm births, research now needs to focus on understanding underlying mechanisms, and then to translate these insights into the development of preventive interventions.

Review Registration

PROSPERO CRD42013004965 Please see later in the article for the Editors'' Summary     

Factors Associated to Prevalence and Incidence of Carbapenem-Resistant Enterobacteriaceae Fecal Carriage: A Cohort Study in a Mexican Tertiary Care Hospital

Background

Carbapenem-resistant Enterobacteriaceae (CRE) infections have emerged as a serious threat to health worldwide. They are associated with increased morbidity and mortality and are capable of silently colonizing the gastrointestinal tract. Because of this, there is great interest to characterize the epidemiology of CRE carriage and acquisition in healthcare facilities. The aim of this study was to determine the prevalence and factors associated with CRE fecal carriage (CRE-fc), and risk factors for incident cases.

Methods/Results

A cohort study was conducted at a tertiary care hospital from January 1^st to April 30^th, 2014 during a CRE outbreak. Weekly rectal swabs were performed in patients considered at risk until discharge. CRE-fc prevalence was 10.9% (CI 95% 7.7–14.7) among 330 patients. Treatment with carbapenems (OR 2.54, CI 95% 1.15–5.62); transfer from an institution (OR 2.16, CI 95% 1.02–4.59); multi-drug resistant infection within the previous six months (OR 2.81, CI 95% 1.47–5.36); intensive care unit admission (OR 0.42, CI 95% 0.20–0.88); hematologic malignancy (OR 4.02, CI 95% 1.88–8.06); invasive procedures (OR 2.18, CI 95% 1.10–4.32); and sharing a room with a known CRE carrier (OR 3.0, CI 95% 1.43–6.31) were independently associated factors for CRE-fc. Risk factors associated with CRE-fc incidence were determined for 87 patients initially negative and with subsequent screening; the incidence rate was 2.5 cases, per 1000 person-years (CI 95% 1.5–3.9). Independently associated risk factors were carbapenem treatment (HR 2.68, CI 95% 1.03–6.98), hematologic malignancy (HR 5.74, 95% CI 2.46–13.4) and a mean daily colonization pressure ≥10% (HR 5.03, IC 95% 1.77–14.28). OXA-48-like (OXA-232) and CTX-M-15 were the predominantly identified mechanisms of resistance.

Conclusions

We found an elevated incidence and prevalence of CRE-fc in our hospital. Hematologic patients need to be considered a population at risk, and antibiotic stewardship along with infection control programs need to be improved to avoid nosocomial spread.     

Birth Outcomes of Latin Americans in Two Countries with Contrasting Immigration Admission Policies: Canada and Spain

Background

We delved into the selective migration hypothesis on health by comparing birth outcomes of Latin American immigrants giving birth in two receiving countries with dissimilar immigration admission policies: Canada and Spain. We hypothesized that a stronger immigrant selection in Canada will reflect more favourable outcomes among Latin Americans giving birth in Canada than among their counterparts giving birth in Spain.

Materials and Methods

We conducted a cross-sectional bi-national comparative study. We analyzed birth data of singleton infants born in Canada (2000–2005) (N = 31,767) and Spain (1998–2007) (N = 150,405) to mothers born in Spanish-speaking Latin American countries. We compared mean birthweight at 37–41 weeks gestation, and low birthweight and preterm birth rates between Latin American immigrants to Canada vs. Spain. Regression analysis for aggregate data was used to obtain Odds Ratios and Mean birthweight differences adjusted for infant sex, maternal age, parity, marital status, and father born in same source country.

Results

Latin American women in Canada had heavier newborns than their same-country counterparts giving birth in Spain, overall [adjusted mean birthweight difference: 101 grams; 95% confidence interval (CI): 98, 104], and within each maternal country of origin. Latin American women in Canada had fewer low birthweight and preterm infants than those giving birth in Spain [adjusted Odds Ratio: 0.88; 95% CI: 0.82, 0.94 for low birthweight, and 0.88; 95% CI: 0.84, 0.93 for preterm birth, respectively].

Conclusion

Latin American immigrant women had better birth outcomes in Canada than in Spain, suggesting a more selective migration in Canada than in Spain.     

Independent and Joint Effects of Prenatal Zinc and Vitamin A Deficiencies on Birthweight in Rural Sidama,Southern Ethiopia: Prospective Cohort Study

Background

The effects of prenatal Zinc Deficiency (ZD) and Vitamin A Deficiency (VAD) on birthweight are controversial and their interaction has not been investigated.

Objective

To assess the independent and interaction effects of prenatal zinc and vitamin A deficiencies on birthweight in rural Sidama, Southern Ethiopia.

Methodology

A community-based prospective cohort study design was employed. Six hundred fifty pregnant women in their second or third trimester were randomly selected and their serum zinc and retinol concentrations were determined. About 575 subjects were successfully followed until delivery and birthweight was measured within 72 hours after delivery. The association between the exposures and birthweight was examined using log-binomial and liner regression analyses. Potential interaction between ZD and VAD was examined using Synergy Index (SI).

Results

The mean birthweight (± standard deviation) was 2896 g (±423). About 16.5% (95% CI: 13.5–19.6%) of the babies had Low Birthweight (LBW). Prenatal ZD and VAD were not significantly associated to LBW with Adjusted Relative Risk (ARR) of 1.25 (95 CI: 0.86–1.82) and 1.27 (95% CI: 0.86–1.87), respectively. Stratified analysis on the basis of gestational trimester showed that the occurrence of the deficiencies neither in the second nor third trimester were associated to LBW. The deficiencies did not show synergetic interaction in causing LBW [SI = 1.04 (95% CI: 0.17–6.28)]. Important risk factors of LBW were maternal illiteracy [RR = 1.80 (95% CI: 1.11–2.93)], female sex of the newborn [RR = 1.79 (95% CI: 1.19–2.67)], primiparity [RR = 1.16 (95% CI: 1.02–1.35)], short maternal stature [RR = 1.63 (95% CI: 1.06–2.51)] and maternal thinness [RR = 1.52 (95% CI: 1.03–2.25)]. In the linear regression model, elevated CRP was also negatively associated to birthweight.

Conclusion

LBW is of public health significance in the locality. The study did not witness any independent or interaction effect of prenatal ZD and VAD on birthweight.     

Pre-Pregnancy BMI,Gestational Weight Gain,and the Risk of Hypertensive Disorders of Pregnancy: A Cohort Study in Wuhan,China

Background

Hypertensive disorders of pregnancy (HDP) are major causes of maternal death worldwide and the risk factors are not fully understood. Few studies have investigated the risk factors for HDP among Chinese women. A cohort study involving 84,656 women was conducted to investigate pre-pregnancy BMI, total gestational weight gain (GWG), and GWG during early pregnancy as risk factors for HDP among Chinese women.

Methods

The study was conducted between 2011–2013 in Wuhan, China, utilizing data from the Maternal and Children Healthcare Information Tracking System of Wuhan. A total of 84,656 women with a live singleton pregnancy were included. Multiple unconditional logistic regression was conducted to evaluate associations between putative risk factors and HDP.

Results

Women who were overweight or obese before pregnancy had an elevated risk of developing HDP (overweight: OR = 2.66, 95% CI = 2.32–3.05; obese: OR = 5.53, 95% CI = 4.28–7.13) compared to their normal weight counterparts. Women with total GWG above the Institute of Medicine (IOM) recommendation had an adjusted OR of 1.72 (95% CI = 1.54–1.93) for HDP compared to women who had GWG within the IOM recommendation. Women with gestational BMI gain >10 kg/m² during pregnancy had an adjusted OR of 3.35 (95% CI = 2.89–3.89) for HDP, compared to women with a gestational BMI gain <5 kg/m². The increased risk of HDP was also observed among women with higher early pregnancy (up to 18 weeks of pregnancy) GWG (>600g/wk: adjusted OR = 1.48, 95% CI = 1.19–1.84).

Conclusion

The results from this study show that maternal pre-pregnancy BMI, early GWG, and total GWG are positively associated with the risk of HDP. Weight control efforts before and during pregnancy may help to reduce the risk of HDP.     

The Impact of Hospice Care on Survival and Healthcare Costs for Patients with Lung Cancer: A National Longitudinal Population-Based Study in Taiwan

Background

The healthcare costs of cancer care are highest in the last month of life. The effect of hospice care on end-of-life (EOL) healthcare costs is not clearly understood.

Purpose

The purpose of this study was to evaluate the effect of hospice care on survival and healthcare costs for lung cancer patients in their final month of life.

Methods

We adopted Taiwan’s National Health Insurance Research Claims Database to analyze data for 3399 adult lung cancer patients who died in 1997–2011. A logistic regression analysis was performed to determine the predictors of high healthcare cost, defined as costs falling above the 90th percentile. Patients who received hospice cares were assigned to a hospice (H) group and those who did not were assigned to a non-hospice (non-H) group.

Results

The patients in the H group had a longer mean (median) survival time than those in the non-H group did (1.40 ± 1.61 y (0.86) vs. 1.10 ± 1.47 (0.61), p<0.001). The non-H group had a lower mean healthcare cost than the H group (US $1,821 ± 2,441 vs. US $1,839 ± 1,638, p<0.001). And, there were a total of 340 patients (10%) with the healthcare costs exceeding the 90th percentile (US $4,721) as the cutoff value of high cost. The non-H group had a higher risk of high cost than the H group because many more cases in the non-H group had lower costs. Moreover, the risk of high health care costs were predicted for patients who did not receive hospice care (odds ratio [OR]: 3.68, 95% confidence interval [CI]: 2.44–5.79), received chemotherapy (OR: 1.51, 95% CI: 1.18–1.96) and intubation (OR: 2.63, 95% CI: 1.64–4.16), and those who had more emergency department visits (OR: 1.78, 95% CI: 1.24–2.52), longer hospital admission in days (OR: 1.08, 95% CI: 1.07–1.09), and received radiotherapy (OR: 1.33, 95% CI: 1.00–1.78). Lower risks of high health care costs were observed in patients with low socioeconomic status (OR: 0.58, 95% CI: 0.40–0.83), or previous employment (OR: 0.66, 95% CI: 0.47–0.92). After propensity-score matching, the patients of the non-H group had a higher mean cost and a higher risk of high cost. Similar results were obtained from logistic regression analysis in propensity score-matched patients.

Conclusions

The survival of the hospice group was longer than non-H group, and patients in the non-H group were 3.74 times more likely to have high healthcare costs at EOL. The positive predictors for high health care costs were patients who did not receive hospice care, who received chemotherapy and intubation, who had more emergency department visits and longer hospital admission, and who received radiotherapy. Negative predictors were patients who had a low socioeconomic status or previous employment. The issue of how to reduce the high health care costs for patients with lung cancer in the last month of life is a challenge for policy makers and health care providers.     

Influence of Maternal Height and Weight on Low Birth Weight: A Cross-Sectional Study in Poor Communities of Northeastern Brazil

Background

Low birth weight (LBW) is associated with an increased risk of mortality, adverse metabolic conditions, and long-term chronic morbidities. The relationship between LWB and short maternal stature coupled with nutritional status was investigated in poor communities.

Methods/Principal Findings

A cross-sectional population-based study involving 2226 mother-child pairs was conducted during the period 2009-2010 in shantytowns of Maceió, Alagoas, Brazil. Associations between LBW and maternal sociodemographics, stature and nutritional status were investigated. The outcome variable was birth weight (< 2500g and ≥ 2500g). The independent variables were the age, income, educational background, stature and nutritional status (eutrophic, underweight, overweight and obese) of the mother. The frequency of LBW was 10%. Short-statured mothers (1^st quartile of stature ≤ 152cm) showed a tendency of increased risk of LBW children compared to mothers in the 4^th quartile of stature (>160.4cm) (OR: 1.42, 95% CI: 0.96 - 1.09, p = 0.078). Children from short-statured mothers weighed an average of 125g less than those from taller mothers (3.18±0.56kg vs. 3.30±0.58kg, respectively p = 0.002). Multivariate analyses showed that short stature, age < 20y (OR: 3.05, 95% CI:1.44 - 6.47) or were underweight (OR: 2.26, 95% CI:0.92 - 5.95) increased the risk of LBW, while overweight (OR: 0.38, 95% CI:0.16 - 0.95) and obesity (OR: 0.39, 95% CI:0.11 - 1.31) had lower risk for LBW. In taller mothers, lower income and underweight were associated with LBW (OR: 1.88, 95% CI: 1.07 - 3.29 and 2.85, 95% CI:1.09 - 7.47, respectively), and obese mothers showed a trend of increased risk of LBW (OR: 1.66, 95% CI:0.84 - 3.25).

Conclusions/Significance

Overweight was found to have a protective effect in short-statured mothers, indicating that a surplus of energy may diminish the risk of LBW. Short-statured younger mothers, but not taller ones, showed higher risk of LBW. The mother being underweight, regardless of stature, was associated with LBW.     

Low Birth Weight,Small for Gestational Age and Preterm Births before and after the Economic Collapse in Iceland: A Population Based Cohort Study

Objective

Infants born small for gestational age (SGA) or preterm have increased rates of perinatal morbidity and mortality. Stressful events have been suggested as potential contributors to preterm birth (PB) and low birth weight (LBW). We studied the effect of the 2008 economic collapse in Iceland on the risks of adverse birth outcomes.

Study design

The study population constituted all Icelandic women giving birth to live-born singletons from January 1^st 2006 to December 31^st 2009. LBW infants were defined as those weighing <2500 grams at birth, PB infants as those born before 37 weeks of gestation and SGA as those with a birth weight for gestational age more than 2 standard deviations (SD''s) below the mean according to the Swedish fetal growth curve. We used logistic regression analysis to estimate odds ratios [OR] and corresponding 95 percent confidence intervals [95% CI] of adverse birth outcomes by exposure to calendar time of the economic collapse, i.e. after October 6^th 2008.

Results

Compared to the preceding period, we observed an increased adjusted odds in LBW-deliveries following the collapse (aOR = 1.24, 95% CI [1.02, 1.52]), particularly among infants born to mothers younger than 25 years (aOR = 1.85, 95% CI [1.25, 2.72]) and not working mothers (aOR = 1.61, 95% CI [1.10, 2.35]). Similarly, we found a tendency towards higher incidence of SGA-births (aOR = 1.14, 95% CI [0.86, 1.51]) particularly among children born to mothers younger than 25 years (aOR = 1.87, 95% CI [1.09, 3.23]) and not working mothers (aOR = 1.86, 95% CI [1.09, 3.17]). No change in risk of PB was observed. The increase of LBW was most distinct 6–9 months after the collapse.

Conclusion

The results suggest an increase in risk of LBW shortly after the collapse of the Icelandic national economy. The increase in LBW seems to be driven by reduced fetal growth rate rather than shorter gestation.     

Relevant Obstetric Factors for Cerebral Palsy: From the Nationwide Obstetric Compensation System in Japan

Objective

The aim of this study was to identify the relevant obstetric factors for cerebral palsy (CP) after 33 weeks’ gestation in Japan.

Study design

This retrospective case cohort study (1:100 cases and controls) used a Japanese national CP registry. Obstetric characteristics and clinical course were compared between CP cases in the Japan Obstetric Compensation System for Cerebral Palsy database and controls in the perinatal database of the Japan Society of Obstetrics and Gynecology born as live singleton infants between 2009 and 2011 with a birth weight ≥ 2,000 g and gestation ≥ 33 weeks.

Results

One hundred and seventy-five CP cases and 17,475 controls were assessed. Major relevant single factors for CP were placental abnormalities (31%), umbilical cord abnormalities (15%), maternal complications (10%), and neonatal complications (1%). A multivariate regression model demonstrated that obstetric variables associated with CP were acute delivery due to non-reassuring fetal status (relative risk [RR]: 37.182, 95% confidence interval [CI]: 20.028–69.032), uterine rupture (RR: 24.770, 95% CI: 6.006–102.160), placental abruption (RR: 20.891, 95% CI: 11.817–36.934), and preterm labor (RR: 3.153, 95% CI: 2.024–4.911), whereas protective factors were head presentation (RR: 0.199, 95% CI: 0.088–0.450) and elective cesarean section (RR: 0.236, 95% CI: 0.067–0.828).

Conclusion

CP after 33 weeks’ gestation in the recently reported cases in Japan was strongly associated with acute delivery due to non-reassuring fetal status, uterine rupture, and placental abruption.     

Risk Factors for Vitamin D Deficiency among Veterans with and without HIV Infection

Objectives

We aimed to describe and compare the prevalence of vitamin D deficiency between HIV-negative and HIV-infected veterans in the southern United States, and to determine risk factors for vitamin D deficiency for HIV infected patients.

Methods

Cross-sectional, retrospective study including all patients followed at the Atlanta VA Medical Center with the first 25-hydroxyvitamin D [25(OH)D] level determined between January 2007 and August 2010. Multivariate logistic regression analysis was used to determine risk factors associated with vitamin D deficiency (< 20 ng/ml).

Results

There was higher prevalence of 25(OH)D deficiency among HIV-positive compared to HIV-negative patients (53.2 vs. 38.5%, p <0.001). Independent risk factors for vitamin D deficiency in HIV + patients included black race (OR 3.24, 95% CI 2.28–4.60), winter season (OR 1.39, 95% CI 1.05–1.84) and higher GFR (OR 1.01, CI 1.00–1.01); increasing age (OR 0.98, 95% CI 0.95–0.98), and tenofovir use (OR 0.72, 95% CI 0.54–0.96) were associated with less vitamin D deficiency.

Conclusions

Vitamin D deficiency is a prevalent problem that varies inversely with age and affects HIV-infected patients more than other veterans in care. In addition to age, tenofovir and kidney disease seem to confer a protective effect from vitamin D deficiency in HIV-positive patients.     

Incidence,Characteristics and Risk Factors of Acute Kidney Injury among Dengue Patients: A Retrospective Analysis

Background

Dengue induced acute kidney injury (AKI) imposes heavy burden of illness in terms of morbidity and mortality. A retrospective study was conducted to investigate incidence, characteristics, risk factors and clinical outcomes of AKI among dengue patients.

Methodology

A total 667 dengue patients (2008–2013) were retrospectively evaluated and were stratified into AKI and non-AKI groups by using AKIN criteria. Two groups were compared by using appropriate statistical methods.

Results

There were 95 patients (14.2%) who had AKI, with AKIN-I, AKIN-II and AKIN-III in 76.8%, 16.8% and 6.4% patients, respectively. Significant differences (P<0.05) in demographics and clinico-laboratory characteristics were observed between patients with and without AKI. Presence of dengue hemorrhagic fever [OR (95% CI): 8.0 (3.64–17.59), P<0.001], rhabdomyolysis [OR (95% CI): 7.9 (3.04–20.49)], multiple organ dysfunction [OR (95% CI): 34.6 (14.14–84.73), P<0.001], diabetes mellitus [OR (95% CI): 4.7 (1.12–19.86), P = 0.034], late hospitalization [OR (95% CI): 2.1 (1.12–19.86), P = 0.033] and use of nephrotoxic drugs [OR (95% CI): 2.9 (1.12–19.86), P = 0.006] were associated with AKI. Longer hospital stay (>3 days) was also observed among AKI patients (OR = 1.3, P = 0.044). Additionally, 48.4% AKI patients had renal insufficiencies at discharge that were signicantly associated with severe dengue, secondary infection and diabetes mellitus. Overall mortality was 1.2% and all fatal cases had AKI.

Conclusions

The incidence of AKI is high at 14.2% among dengue patients, and those with AKI portended significant morbidity, mortality, longer hospital stay and poor renal outcomes. Our findings suggest that AKI in dengue is likely to increase healthcare burden that underscores the need of clinicians’ alertness to this highly morbid and potentially fatal complication for optimal prevention and management.     

Maternal Gestational Smoking,Diabetes, Alcohol Drinking,Pre-Pregnancy Obesity and the Risk of Cryptorchidism: A Systematic Review and Meta-Analysis of Observational Studies

Background

Maternal gestational smoking, diabetes, alcohol drinking, and pre-pregnancy obesity are thought to increase the risk of cryptorchidism in newborn males, but the evidence is inconsistent.

Method

We conducted a systematic review and meta-analysis of studies on the association between maternal gestational smoking, diabetes, alcohol drinking, and pre-pregnancy obesity and the risk of cryptorchidism. Articles were retrieved by searching PubMed and ScienceDirect, and the meta-analysis was conducted using Stata/SE 12.0 software. Sensitivity analysis was used to evaluate the influence of confounding variables.

Results

We selected 32 articles, including 12 case—control, five nested case—control, and 15 cohort studies. The meta-analysis showed that maternal smoking (OR = 1.17, 95% CI: 1.11–1.23) or diabetes (OR = 1.21, 95%CI: 1.00–1.46) during pregnancy were associated with increased risk of cryptorchidism. Overall, the association between maternal alcohol drinking (OR = 0.97, 95% CI: 0.87–1.07), pre-pregnancy body mass index (OR = 1.02, 95% CI: 0.95–1.09) and risk of cryptorchidism were not statistically significant. Additional analysis showed reduced risk (OR = 0.89, 95% CI: 0.82–0.96) of cryptorchidism with moderate alcohol drinking during pregnancy. No dose—response relationship was observed for increments in body mass index in the risk of cryptorchidism. Sensitivity analysis revealed an unstable result for the association between maternal diabetes, alcohol drinking and cryptorchidism. Moderate heterogeneity was detected in studies of the effect of maternal alcohol drinking and diabetes. No publication bias was detected.

Conclusion

Maternal gestational smoking, but not maternal pre-pregnancy overweight or obesity, was associated with increased cryptorchidism risk in the offspring. Moderate alcohol drinking may reduce the risk of cryptorchidism while gestational diabetes may be a risk factor, but further studies are needed to verify this.     

Maternal and Neonatal Mortality in South-West Ethiopia: Estimates and Socio-Economic Inequality

Introduction

Ethiopia has achieved the fourth Millennium Development Goal by reducing under 5 mortality. Nevertheless, there are challenges in reducing maternal and neonatal mortality. The aim of this study was to estimate maternal and neonatal mortality and the socio-economic inequalities of these mortalities in rural south-west Ethiopia.

Methods

We visited and enumerated all households but collected data from those that reported pregnancy and birth outcomes in the last five years in 15 of the 30 rural kebeles in Bonke woreda, Gamo Gofa, south-west Ethiopia. The primary outcomes were maternal and neonatal mortality and a secondary outcome was the rate of institutional delivery.

Results

We found 11,762 births in 6572 households; 11,536 live and 226 stillbirths. There were 49 maternal deaths; yielding a maternal mortality ratio of 425 per 100,000 live births (95% CI:318–556). The poorest households had greater MMR compared to richest (550 vs 239 per 100,000 live births). However, the socio-economic factors examined did not have statistically significant association with maternal mortality. There were 308 neonatal deaths; resulting in a neonatal mortality ratio of 27 per 1000 live births (95% CI: 24–30). Neonatal mortality was greater in households in the poorest quartile compared to the richest; adjusted OR (AOR): 2.62 (95% CI: 1.65–4.15), headed by illiterates compared to better educated; AOR: 3.54 (95% CI: 1.11–11.30), far from road (≥6 km) compared to within 5 km; AOR: 2.40 (95% CI: 1.56–3.69), that had three or more births in five years compared to two or less; AOR: 3.22 (95% CI: 2.45–4.22). Households with maternal mortality had an increased risk of stillbirths; OR: 11.6 (95% CI: 6.00–22.7), and neonatal deaths; OR: 7.2 (95% CI: 3.6–14.3). Institutional delivery was only 3.7%.

Conclusion

High mortality with socio-economic inequality and low institutional delivery highlight the importance of strengthening obstetric interventions in rural south-west Ethiopia.