Factors associated with unfavourable birth outcomes in Kenya

Studies addressing factors associated with adverse birth outcomes have almost exclusively been based on hospital statistics. This is a serious limitation in developing countries where the majority of births do not occur within health facilities. This paper examines factors associated with premature deliveries, small baby's size at birth and Caesarean section deliveries in Kenya based on the 1993 Kenya Demographic and Health Survey data. Due to the hierarchical nature of the data, the analysis uses multilevel logistic regression models to take into account the family and community effects. The results show that the odds of unfavourable birth outcomes are significantly higher for first births than for higher order births. Furthermore, antenatal care (measured by frequency of antenatal care visits and tetanus toxoid injection) is observed to have a negative association with the incidence of premature births. For the baby's size at birth, maternal nutritional status is observed to be a predominant factor. Short maternal stature is confirmed as a significant risk factor for Caesarean section deliveries. The observed higher odds of Caesarean section deliveries among women from households of high socioeconomic status are attributed to the expected association between socioeconomic status and the use of appropriate maternal health care services. The odds of unfavourable birth outcomes vary significantly between women. In addition, the odds of Caesarean section deliveries vary between districts, after taking into account the individual-level characteristics of the woman.     

The COVID-19 pandemic and birth outcomes in 2020: The role of prenatal care and other channels

We use national birth data to assess the associations between the COVID-19 pandemic during 2020 and birth outcomes in Uruguay. Employing interrupted time series difference-in-differences techniques, we find mixed results, with some pregnancies showing increases in the likelihood of very preterm or very-low-weight births, and some others showing decreases in the incidence of moderate prematurity and moderate low birth weight. Adverse outcomes are more likely among women with low education, women with previous children, and with risk factors, such as smoking or being older than 34. We observe improvements in health at birth for children of non-smokers, women younger than 35, and women with no other children. We underscore the role of health care by showing that women in the private sector, who suffered the strongest contraction in face-to-face prenatal care use, experienced more adverse birth outcomes. Our results also suggest that the economic recession and an increased burden of childcare were behind the increases in preterm and very-low-weight births. Because pollution is an unlikely channel for the positive results, we hypothesize that for some pregnancies, the pandemic improved the intrauterine habitat by leading to a quieter and healthier lifestyle.     

Maternal and Neonatal Outcomes among Pregnant Women with 2009 Pandemic Influenza A(H1N1) Illness in Florida, 2009-2010: A Population-Based Cohort Study

Introduction

Pregnant women have been identified as a high risk group for severe illness with 2009 pandemic influenza A(H1N1) virus infection (pH1N1). Obesity has also been identified as a risk factor for severe illness, though this has not been thoroughly assessed among pregnant women. The objectives of this study were to provide risk estimates for adverse maternal and neonatal outcomes associated with pH1N1 illness during pregnancy and to assess the role of obesity in these outcomes.

Methods

We established a retrospective population-based cohort of all live births occurring in Florida during the first 15 months of the pandemic. Illness with pH1N1 during pregnancy was ascertained through record linkage with the Florida state notifiable disease surveillance database. Data from the birth record, including pre-pregnancy body mass index, were analyzed to assess risk of adverse outcomes associated with pH1N1 illness.

Results

A total of 194 women were identified through surveillance with pH1N1 illness during pregnancy. Children born to women with pH1N1 illness during pregnancy were at increased risk for low birth weight [OR (95%CI): 1.78 (1.11-2.860)], premature birth [2.21 (1.47-3.330)], and infant death [4.46 (1.80-11.00)], after adjusting for other factors. Women with pH1N1 illness during pregnancy were at increased risk for severe outcomes including admission to an intensive care unit. Obesity was an observed risk factor, both for the more severe pH1N1 illness detected through surveillance, and for severe maternal outcomes.

Conclusions

Case-patients in this analysis likely represent the most severely ill subset of all women infected with pH1N1 during pregnancy, limiting the generalizability of these findings to more severely ill patients rather than influenza infection in general. Nevertheless, these results suggest that more severe pH1N1 illness during pregnancy is associated with adverse neonatal outcomes and that pregnant women should continue to be targeted for appropriate prophylaxis and early treatment.     

Destruction and reconstruction: hypoxia and the developing brain

Preterm infants have a high rate of neurodevelopmental handicap. Recent imaging studies have revealed that adverse outcomes are strongly associated with reduced brain growth and neural complexity in later life. Increasing data suggest that these chronic deficits primarily reflect acute neuronal and glial injury sustained during adverse in utero events, such as exposure to severe hypoxia-ischemia and inflammation. In the present review we examine recent evidence that this chronic impairment is partly due to upregulation of physiological apoptosis, related to input deprivation, and output isolation secondary to acute white and gray matter damage and axonal injury. However, progenitor cells in the subventricular zone (SVZ) are also vulnerable to injury, and loss of part of this critical population likely further compromises brain development. Based on these concepts the impact of proposed interventions such as induced hypothermia and endogenous growth factors are likely to be complex, but potentially offer focused ways of improving the outcomes of premature birth.     

Adequate Prenatal Care Reduces the Risk of Adverse Pregnancy Outcomes in Women with History of Infertility: A Nationwide Population-Based Study

Objectives

To investigate the effects of various measures of prenatal care on adverse pregnancy outcomes in women with a history of infertility.

Study Design

A retrospective cohort study.

Methods

Data were derived by linking 2 large nationwide population-based datasets, the National Health Insurance Research Database and Taiwan Birth Certificate Registry. The study sample included 15,056 women with an infertility diagnosis and 60,224 randomly selected women without infertility matched to the study sample by maternal age. A conditional logistic regression analysis was performed for the analysis.

Results

Women diagnosed with infertility respectively had 1.39 (95% CI, 1.06~1.83), 1.15 (95% CI, 1.08~1.24), 1.13 (95% CI, 1.08~1.18), and 1.08 (95% CI, 1.05~1.12) higher odds of having very low birth weight (VLBW) babies, preterm births, labor complications, and cesarean sections (CSs) compared to women without infertility. Inadequate numbers of total and major prenatal visits and late initiation of prenatal care increased the risks of adverse pregnancy outcomes in women with infertility, especially the risk of a VLBW baby. However, no significant associations were found for the risks of adverse birth outcomes in infertile women with adequate prenatal care compared to fertile women with adequate care.

Conclusions

Study findings suggest that adequate prenatal care can reduce the risk of adverse pregnancy outcomes in women with infertility.     

Maternal Vaccination to Prevent Adverse Pregnancy Outcomes: An Underutilized Molecular Immunological Intervention?

Adverse pregnancy outcomes including maternal mortality, stillbirth, preterm birth, intrauterine growth restriction cause millions of deaths each year. More effective interventions are urgently needed. Maternal immunization could be one such intervention protecting the mother and newborn from infection through its pathogen-specific effects. However, many adverse pregnancy outcomes are not directly linked to the infectious pathogens targeted by existing maternal vaccines but rather are linked to pathological inflammation unfolding during pregnancy. The underlying pathogenesis driving such unfavourable outcomes have only partially been elucidated but appear to relate to altered immune regulation by innate as well as adaptive immune responses, ultimately leading to aberrant maternal immune activation. Maternal immunization, like all immunization, impacts the immune system beyond pathogen-specific immunity. This raises the possibility that maternal vaccination could potentially be utilised as a pathogen-agnostic immune modulatory intervention to redirect abnormal immune trajectories towards a more favourable phenotype providing pregnancy protection. In this review we describe the epidemiological evidence surrounding this hypothesis, along with the mechanistic plausibility and present a possible path forward to accelerate addressing the urgent need of adverse pregnancy outcomes.     

Arrangements for special and intensive care of the newborn.

All the special care baby units in three Thames health regions completed a one-day census on the number of infants in the unit, staffing, and facilities. The results were assessed in the light of the recommendations of an expert group set up by the Department of Health and Social Security. Although the provision of cots (6.1-6.9 per 1000 live births) was more generous than the estimated need and the occupancy rate (59--63%) lower than suggested, some units did not have adequate trained nursing cover at night, some did not have resident paediatricians, and some lacked essential equipment. Some small units, on the other hand, had very expensive equipment that was probably underused. Relating this provision to the regional statistics on babies needing special care showed that there was room for the rationalisation of facilities for their care. Factors that should be considered in planning such care include the size of the child-bearing population, the percentage of infants of low birth weights, and the proximity of specialist paediatric and maternity units and pathology facilities. It is also essential to monitor the effectiveness of the care by assessing the outcome in babies admitted to special units, especially those of low birth weight.     

A potential outcomes approach to developmental toxicity analyses

Estimating the effects of a toxin on fetal development in animal models such as mice can be problematic, because the number of pups that develop and survive until birth may simultaneously affect developmental outcomes such as birth weight and be affected by the introduction of a toxin into the fetal environment. Also, comparing pups that survived until birth at a high dose of the toxin with pups that survived at low doses may underestimate the effect of the toxin, because the lower dose means include the less healthy pups that would not survive if exposed to a higher level of toxin. We consider this problem in a potential outcomes framework that defines the effect of the dose on the outcome as the difference between what the outcome would have been for a pup had the dam in which the pup develops been exposed to dose level Z=z* rather than dose level Z=z. To disentangle the direct effect of dose from the effect of litter size, we focus on effects defined within principal strata that are a function of the survival status of the pups at each of the possible dose levels. A unique contribution to the potential outcomes literature is that we allow the outcome for a subject to be dependent on the principal stratum to which other subjects within a cluster belong.     

Genome wide association study of Escherichia coli bloodstream infection isolates identifies genetic determinants for the portal of entry but not fatal outcome

Escherichia coli is an important cause of bloodstream infections (BSI), which is of concern given its high mortality and increasing worldwide prevalence. Finding bacterial genetic variants that might contribute to patient death is of interest to better understand infection progression and implement diagnostic methods that specifically look for those factors. E. coli samples isolated from patients with BSI are an ideal dataset to systematically search for those variants, as long as the influence of host factors such as comorbidities are taken into account. Here we performed a genome-wide association study (GWAS) using data from 912 patients with E. coli BSI from hospitals in Paris, France. We looked for associations between bacterial genetic variants and three patient outcomes (death at 28 days, septic shock and admission to intensive care unit), as well as two portals of entry (urinary and digestive tract), using various clinical variables from each patient to account for host factors. We did not find any association between genetic variants and patient outcomes, potentially confirming the strong influence of host factors in influencing the course of BSI; we however found a strong association between the papGII operon and entrance of E. coli through the urinary tract, which demonstrates the power of bacterial GWAS when applied to actual clinical data. Despite the lack of associations between E. coli genetic variants and patient outcomes, we estimate that increasing the sample size by one order of magnitude could lead to the discovery of some putative causal variants. Given the wide adoption of bacterial genome sequencing of clinical isolates, such sample sizes may be soon available.     

Season of birth and reproductive performance: an analysis of family reconstitutions of 800 women born in The Netherlands at the end of the 19th century

Background: Several studies have reported associations between season of birth and reproductive characteristics such as menarcheal age, fecundability, and twinning, but the results are inconsistent with respect to the location of high- and low-risk seasons. To assess whether this disagreement could be due to the use of populations from different geographic areas and time frames instead of different etiologic pathways, we investigated the season-of-birth dependency of a variety of reproductive outcomes within one time- and arealimited population. Methods: In a historic follow-up study, the reconstituted families of 800 women born between 1873 and 1887 in or near Rotterdam, The Netherlands, were used to determine eight types of reproductive outcome: childlessness, interval to first pregnancy, pregnancy interval, stillbirth, neonatal death, postneonatal death, multiple birth, and gender of offspring. The relation of these outcomes with season of birth was modeled using cosinor functions with periods of 1 year or a half year. Data were analyzed by use of logistic regression or general estimation equations (GEE), dependent on whether outcomes could occur more than once per woman. Results: Peaks in the model-based risks of reproductive failure were found within two small temporal ranges, January 1 to February 11 and July 1 to August 11 for all outcomes except gender. The picture did not change after controlling for known and possible risk factors, including age, offspring's birth cohort, and some social variables. Conclusions: This study reconfirms the idea that seasonal factors around conception or birth influence later reproductive characteristics. Observing the consistency of the location of high-risk seasons across a variety of outcomes, the explanation of season-of-birth dependency of different reproductive outcomes need not involve multiple etiological pathways. (Chronobiology International, 18(3), 525-539, 2001)     

Association between length of gestation and cervical DNA methylation of PTGER2 and LINE 1-HS

Worldwide, more than 1 in 10 infants is born prior to 37 weeks gestation. Preterm birth can lead to increased mortality risk and poor life-long health and neurodevelopmental outcomes. Whether environmental risk factors affect preterm birth through epigenetic phenomena is largely unstudied. We sought to determine whether preterm risk factors, such as smoke exposure and education, were associated with cervical DNA methylation in the prostaglandin E receptor 2 gene (PTGER2) and a repetitive element, long interspersed nuclear element-1 Homo sapiens-specific (LINE 1-HS). Second, we aimed to determine whether mid-pregnancy DNA methylation of these regions in cervical samples could predict the length of gestation. We obtained a cervical swab between 16–19 weeks gestation from 80 women participating in a Mexico City birth cohort, used pyrosequencing to analyze DNA methylation of PTGER2 and LINE 1-HS, and examined associations with maternal covariates. We used accelerated failure time models to analyze associations of DNA methylation with the length of gestation. DNA methylation of both sequences was associated with Pap smear inflammation. LINE 1-HS methylation was associated with smoke exposure, BMI and parity. In adjusted models, gestations were 3.3 days longer (95%CI 0.6, 6.0) for each interquartile range of PTGER2 DNA methylation. Higher LINE 1-HS methylation was associated with shorter gestations (-3.3 days, 95%CI -6.5, -0.2). In conclusion, cervical DNA methylation was associated with risk factors for preterm birth and the length of gestation.     

Association between length of gestation and cervical DNA methylation of PTGER2 and LINE 1-HS

Worldwide, more than 1 in 10 infants is born prior to 37 weeks gestation. Preterm birth can lead to increased mortality risk and poor life-long health and neurodevelopmental outcomes. Whether environmental risk factors affect preterm birth through epigenetic phenomena is largely unstudied. We sought to determine whether preterm risk factors, such as smoke exposure and education, were associated with cervical DNA methylation in the prostaglandin E receptor 2 gene (PTGER2) and a repetitive element, long interspersed nuclear element-1 Homo sapiens-specific (LINE 1-HS). Second, we aimed to determine whether mid-pregnancy DNA methylation of these regions in cervical samples could predict the length of gestation. We obtained a cervical swab between 16–19 weeks gestation from 80 women participating in a Mexico City birth cohort, used pyrosequencing to analyze DNA methylation of PTGER2 and LINE 1-HS, and examined associations with maternal covariates. We used accelerated failure time models to analyze associations of DNA methylation with the length of gestation. DNA methylation of both sequences was associated with Pap smear inflammation. LINE 1-HS methylation was associated with smoke exposure, BMI and parity. In adjusted models, gestations were 3.3 days longer (95%CI 0.6, 6.0) for each interquartile range of PTGER2 DNA methylation. Higher LINE 1-HS methylation was associated with shorter gestations (-3.3 days, 95%CI -6.5, -0.2). In conclusion, cervical DNA methylation was associated with risk factors for preterm birth and the length of gestation.     

Fragile lives with fragile rights: Justice for babies born at the limit of viability

There is an inconsistency in the ways that doctors make clinical decisions regarding the treatment of babies born extremely prematurely. Many experts now recommend that clinical decisions about the treatment of such babies be individualized and consider many different factors. Nevertheless, many policies and practices throughout Europe and North America still appear to base decisions on gestational age alone or on gestational age as the primary factor that determines whether doctors recommend or even offer life‐sustaining neonatal intensive care treatment. These policies are well intentioned. They aim to guide doctors and parents to make decisions that are best for the baby. That is an ethically appropriate goal. But in relying so heavily on gestational age, such policies may actually do the babies a disservice by denying some babies treatment that might be beneficial and lead to intact survival. In this paper, we argue that such policies are unjust to premature babies and ought to be abolished. In their place, we propose individualized treatment decisions for premature babies. This would treat premature babies as we treat all other patients, with clinical decisions based on an individualized estimation of likelihood that treatment would be beneficial.     

PHYLOGENETIC ANALYSES REVEAL UNEXPECTED PATTERNS IN THE EVOLUTION OF REPRODUCTIVE MODES IN FROGS

Understanding phenotypic diversity requires not only identification of selective factors that favor origins of derived states, but also factors that favor retention of primitive states. Anurans (frogs and toads) exhibit a remarkable diversity of reproductive modes that is unique among terrestrial vertebrates. Here, we analyze the evolution of these modes, using comparative methods on a phylogeny and matched life‐history database of 720 species, including most families and modes. As expected, modes with terrestrial eggs and aquatic larvae often precede direct development (terrestrial egg, no tadpole stage), but surprisingly, direct development evolves directly from aquatic breeding nearly as often. Modes with primitive exotrophic larvae (feeding outside the egg) frequently give rise to direct developers, whereas those with nonfeeding larvae (endotrophic) do not. Similarly, modes with eggs and larvae placed in locations protected from aquatic predators evolve frequently but rarely give rise to direct developers. Thus, frogs frequently bypass many seemingly intermediate stages in the evolution of direct development. We also find significant associations between terrestrial reproduction and reduced clutch size, larger egg size, reduced adult size, parental care, and occurrence in wetter and warmer regions. These associations may help explain the widespread retention of aquatic eggs and larvae, and the overall diversity of anuran reproductive modes.     

Family centred care for the neonate -- the view from Wolverhampton

The increased technology of neonatal intensive care has meant that babies born at increasingly lower gestational age are surviving to be discharged home. A family centred approach in neonatal care supports the move toward patient or parent empowerment, which is vital, if babies are to be fully integrated into the family unit. Nurses are essential to the success of this process as they have the most direct and prolonged contact with both family and their baby. Critical care areas such as Neonatal Units (NNU) can be adjusted to support a more family focused philosophy. In Wolverhampton Orems 'Self-Care Model' of self care has been adapted to the family as the self care unit and simple adjustments to the area such as Quiet Times supports families feeling of well being and control.     

Father Absence and Reproduction-Related Outcomes in Malaysia,a Transitional Fertility Population

Father absence is consistently associated with children’s reproductive outcomes in industrialized countries. It has been suggested that father absence acts as a cue to particular environmental conditions that influence life history strategies. Much less is known, however, about the effects of father absence on such outcomes in lower-income countries. Using data from the 1988 Malaysian Family Life Survey (n?=?567), we tested the effect of father absence on daughters’ age at menarche, first marriage, and first birth; parity progression rates; and desired completed family size in Malaysia, a country undergoing an economic and fertility transition. Father absence during later childhood (ages 8 to 15), although not during earlier childhood, was associated with earlier progressions to first marriage and first birth, after controlling for other confounders. Father absence does not affect age at menarche, desired family size, or progression from first to second birth. The patterns found in this transitional population partly mirror those in developed societies, where father absence accelerates reproductive events. There is, however, a notable contrast between the acceleration in menarche for father-absent girls consistently found in developed societies and the lack of any association in our findings. The mechanisms through which father absence affects reproduction may differ in different ecological contexts. In lower-income contexts, direct paternal investment or influence may be of more importance in determining reproductive behavior than whether fathers act as a cue to environmental conditions.     

Risk factors for gastroschisis

The prevalence at birth of gastroschisis, a rare abnormality of the abdominal wall, appears to have increased over the past decade. To characterize risk factors that might explain this increase, birth certificates for Washington State residents were compared for 62 infants born with gastroschisis during the years 1984 to 1987 and 617 randomly selected unaffected infants matched for birth year. After simultaneously adjusting for 14 potential risk factors, 4 factors stood out. Infants born during January, February, or March were at greater risk than infants born in any other months (odds ratio 2.2, 95% confidence interval 1.1, 4.1). Mothers less than 25 years old were at greater risk than mothers 25 years and older, with the highest risk to mothers less than 20 years old (odds ratio 4.1, 95% confidence interval 1.4, 12.0). Women who smoked during pregnancy were at greater risk than women who did not smoke (odds ratio 2.0, 95% confidence interval 1.03, 3.8). Finally, mothers receiving inadequate prenatal care were at greater risk than mothers receiving adequate prenatal care (odds ratio 2.1, 95% confidence interval 0.99, 4.6). Unidentified behavioral and environmental exposures may explain the associations with month of birth, maternal age, and prenatal care. However, smoking during pregnancy is a plausible risk factor that should be examined further as an explanation of the apparently increasing prevalence at birth of gastroschisis in developed nations.     

Life-history patterns and sociality in canids: Body size,reproduction, and behavior

Summary Empirical associations among co-adapted traits such as body size and patterns of reproduction, development, and behavior are unknown for most animal species, despite numerous theories suggesting otherwise. One way to study these complex relationships is first to consider closely related species and then to generalize findings to other groups. In the present study, relationships among body size, reproductive patterns, development, and sociality were examined in 17 members of the family Canidae (canids). Large canids are more social than smaller species, and offspring of large species achieve independence and tend to breed first at a later age. Large females give birth to absolutely larger young, but relative to their own body weight they allocate fewer resources to bringing a large pup to term. Overall, sexual dimorphism in size is small to moderate, and this is associated with monogamous mating habits and paternal care of young.     

SEASON OF BIRTH AND REPRODUCTIVE PERFORMANCE: AN ANALYSIS OF FAMILY RECONSTITUTIONS OF 800 WOMEN BORN IN THE NETHERLANDS AT THE END OF THE 19TH CENTURY

Background: Several studies have reported associations between season of birth and reproductive characteristics such as menarcheal age, fecundability, and twinning, but the results are inconsistent with respect to the location of high- and low-risk seasons. To assess whether this disagreement could be due to the use of populations from different geographic areas and time frames instead of different etiologic pathways, we investigated the season-of-birth dependency of a variety of reproductive outcomes within one time- and arealimited population. Methods: In a historic follow-up study, the reconstituted families of 800 women born between 1873 and 1887 in or near Rotterdam, The Netherlands, were used to determine eight types of reproductive outcome: childlessness, interval to first pregnancy, pregnancy interval, stillbirth, neonatal death, postneonatal death, multiple birth, and gender of offspring. The relation of these outcomes with season of birth was modeled using cosinor functions with periods of 1 year or a half year. Data were analyzed by use of logistic regression or general estimation equations (GEE), dependent on whether outcomes could occur more than once per woman. Results: Peaks in the model-based risks of reproductive failure were found within two small temporal ranges, January 1 to February 11 and July 1 to August 11 for all outcomes except gender. The picture did not change after controlling for known and possible risk factors, including age, offspring's birth cohort, and some social variables. Conclusions: This study reconfirms the idea that seasonal factors around conception or birth influence later reproductive characteristics. Observing the consistency of the location of high-risk seasons across a variety of outcomes, the explanation of season-of-birth dependency of different reproductive outcomes need not involve multiple etiological pathways. (Chronobiology International, 18(3), 525–539, 2001)