Puerperal morbidity: A neglected area of maternal health in Sri Lanka

Abstract

Data on women with at least two children are used to examine how the breastfeeding experience with the first child affects whether subsequent children are breastfed. Our results indicate that women most often repeat with later children the feeding decision they made with their first child. That is, those who breastfed their first child are very likely to breastfeed a later child and those who did not breastfeed their firstborn are unlikely to breastfeed a later‐bom. Among those who did not breastfeed their first child, education beyond high school increases the likelihood that they will switch to breastfeeding with a later‐born. Those who breastfed their first child are less likely to breastfeed a later‐born if the first breastfeeding experience was of short duration or was perceived to be unsuccessful or unsatisfactory or if the woman had not gone beyond high school or received anesthesia at the later birth. Hence, educational differences are greater at higher parities than at first parity.     

Stability of the Association between Birth Weight and Childhood Overweight during the Development of the Obesity Epidemic

Objective: To assess whether changes in the birth weight distribution or changes in the association of birth weight with the later risk of childhood overweight have contributed to the development of the obesity epidemic. Research Methods and Procedures: A Danish population‐based cohort study of 124,615 girls and 128,346 boys (ages 6 to 13 years), born between 1936 and 1983, were studied. Birth weight and annual measurements of height and weight were obtained from school health records. Overweight was defined by BMI in relation to internationally accepted criteria. The relative risk of being overweight by birth weight was calculated separately for each age, sex, and time period. Results: The birth weight distribution remained relatively stable over time. Compared with children with a birth weight of 3.0 to 3.5 kg, the risk of overweight increased consistently with each increase in birth weight category among girls and boys and at all ages between 6 and 13 years. Furthermore, the association between birth weight and increased risk of overweight in childhood remained stable across a 48‐year period. Discussion: The increase in the prevalence of overweight could not be explained by time trends in the distribution of birth weight or by changes in the association between birth weight and the later risk of overweight over time. This implies that, unless the prenatal environment influences the later risk of overweight without increasing birth weight, the environmental influences contributing to the obesity epidemic in children of school age operate in the early postnatal period.     

Patterns of low birth weight in the Bengali newborns

This paper examines the distribution of low birth weight (2500 g or less) by gestation time, sex, maternal age, parity (birth order), socioeconomic conditions, and season of birth among 5117 single live births born to Bengali mothers at the Ramakrishna Mission Seva Pratisthan Hospital in Calcutta, India. Preterm infants have low birth weight significantly more often than their full term counterparts. Female infants have low birth weights significantly more often than male infants. The infants of poor mothers have lower birth weights in higher order births more often than infants of higher orders born to well-off mothers. Teenaged mothers produce low birth weight babies significantly more often than older mothers. Although the relationship is not significant, low birth weight infants occur more often among 1st and late born infants and less often among 2nd born infants. The season of birth is not significantly associated with birth weight. Less than 10% of low birth weight infants are pre-term, while the rest are full term. The great majority of low birth weight infants are small-for-gestational-age; the minority are small due to curtailed gestational age. The proportion of infants weighing less than 2001 g is only 9%; this figure tallies closely with earlier studies of India.     

Maternal age at last birth in Egypt

To assess the effects of women's education, residence, and marital experience on their age at the birth of their last child, a proportional hazards regression model was applied to 1980 Egyptian Fertility Survey (EFS) data. The detailed data include the date of birth of each child for every women interviewed, and the woman's date of birth and age at interview. Age at last birth was examined by regression analysis on birth history and socioeconomic information. 4 hypotheses were tested: women who are well educated have a greater probability of ending childbearing earlier than women with less education; women in rural areas have a higher probability of having their last child at older ages than urban women; marital disruption without remarriage lowers the probability of older maternal age at last birth; and marital disruption with remarriage increases the probability that a woman stops reproducing at an older age. The overall chi-square indicates a significant regression. All coefficients were significant, except the coefficient for women with intact 1st marriages. Women with more education had a greater probability of ending childbearing earlier than women with less education. Rural women tended to have their last children at ages significantly older than overall age at last birth. Current residence in urban areas had the opposite effect. The coefficient for those with intact 1st marriages was insignificant, meaning that the mean age at last birth for this group of women was not much different from the overall mean. Remarried women tended to end childbearing at ages significantly older than the overall average age at last birth, suggesting that these women tended to have children by their new husbands. Those with dissolved 1st marriages who had not remarried had a higher probability of ending childbearing earlier than did older women. Marriage age and final parity had highly significant negative coefficients; as marriage age and number of children born increased, so did the "survival" time or the age at last birth. Results from the hazards model indicate that the effects were as anticipated. The median age at last birth for the total sample of women aged 45-49 was 45-49 years. The median age at last birth was about 2 years older for rural compared to urban women. Illiterate women had the oldest median age at last birth of the education groups. There was little differences between median ages at last birth for women with intact 1st marriages and those whose 1st unions were dissolved and who had remarried. The median age at last birth increased with final parity.     

Parental age,birth order and tertiary sex ratio in the human population of Punjab,Pakistan

The data of this study, an extension of a previous study on secondary sex ratio in the human population of Muridke, Punjab, Pakistan, are based on the population of Muridke, 27 km north of Lahore, Punjab, Pakistan. Records of deaths of children, at later stages of birth, for different birth ranks, and that of maternal and paternal ages were made. 1000 families were scored for this study. Families providing the required information were included. Data for paternal age and maternal age combination consisted of 4807 total number of children of which 2586 were male. Paternal age and birth order combination was comprised of a total of 4405 children, containing 2316 males. Maternal age and birth order combination consisted of 4658 children, of which 2458 were males. The discrepancy in the number of children in the 3 types of combinations was due to the lack of required information in different groups. Sex ratio based on total number of males in relation to paternal age and maternal age was 0.54. Younger fathers (15-19 years) showed higher sex ratio (0.69). This dropped in paternal age groups 20-24 years (0.59) and 25-29 years (0.51). Younger mothers (15-19 years) showed higher sex ratio (0.62), declines in the age groups 20-24 years (0.52) and 25-29 years (0.51) and rise in age groups 35-39 years (0.55) and 40-44 years (0.54). Chi-square tests were carried out to compare the number of male and female offspring in the paternal age groups 15-19, 20-24, and 25-29 years. These showed highly significant deviation from the expected number. The higher age groups showed nonsignificant differences in the number of male and female offspring. Maternal age groups 15-19, 20-24, and 25-29 years showed highly significant differences in the male and female offspring and nonsignificant results in the higher age groups. Maternal age in relation to paternal age showed positive simple and partial correlations. Sex ratio for the total number of males based on paternal age and birth order was 0.52. 1st birth order showed higher sex ratio (0.55) and decreased in the 2nd (0.50) and 3rd birth orders (0.51), showed increase in the 4th birth order (0.53) and declines in the higher birth ranks. The number of male and female offspring in the birth orders 1, 2, and 3 showed significant differences, but in higher birth ranks the difference was insignificant. Paternal age and birth order indicated positive simple and partial correlations. Higher sex ratio (0.58) was seen in the 1st birth order and then it decreased in the 2nd (0.50) and 3rd (0.51) birth order. Chi-square tests carried out to compare the number of male and female offspring in borth orders 1, 2, and 3 showed highly significant differences but in higher birth ranks the difference was insignificant.     

Gestational Age at Birth and ‘Body-Mind’ Health at 5 Years of Age: A Population Based Cohort Study

Numerous studies have identified the effects of prematurity on the neonate’s physical health, however few studies have explored the effects of prematurity on both the physical and mental health of the child as they develop. Secondary analysis of data from the Millennium Cohort Study, a longitudinal study of infants (n = 18 818, born 2000–2002 in the United Kingdom) was performed. Effects of gestational age at birth on health outcomes at 5 years were measured using parental rating of their children’s general health and severity of behavior problems. The association between parent’s general health ratings and behavior problem ratings was low: 86% of those reporting serious behavior problems (5% of the sample, n = 764) rated their child as being in excellent, very good, or good health. Still, a gradient of increasing risk of poorer outcome with decreasing gestational age was observed for a composite health measure (poor/fair health and/or serious behavior problems), suggesting an association with prematurity for this composite assessment of health status. The greatest contribution to the childhood composite health measure at 5 years was for children born at 32–36 weeks gestation: population attributable fractions for having poor outcomes was 3.4% (Bonferroni-adjusted 95% confidence interval 1.1%–6.2%), compared to 1% (0.2–2.3) for birth at less than 32 weeks. Results suggest that preterm children, by school entry, are not only at high risk of physical health problems, but also of behavioral health problems. The recognition of, and response to comprehensive health and well-being outcomes related to prematurity are important in order to correctly plan and deliver adequate paediatric health services and policies.     

Effect of birth spacing on infant and child mortality in rural Nepal

This examination of the effect of birth spacing on infant and child mortality in rural Nepal is based on data from the Nepal Fertility Survey 1976 carried out by the Nepal Family Planning and Maternal Child Health Project in collaboration with the World Fertility Survey. The study confirms that the higher risk of infant death to 1st born children is mainly due to the higher proportion of younger women having 1st births, rather than due to their being 1st order births per se. The effect of maternal age on infant and child mortality is largely associated with birth interval. Previous birth interval, therefore, stands out as the most important factor affecting infant mortality; the next most important factor is the survival of the preceding child. A child born after an interval of less than 18 months since the previous live birth has a 31% higher risk of dying during infancy than 1 born after an interval of 1 1/2 to 2 years. The risk of the index child's dying is only 50% of that when its preceding sibling is dead. Neither education of mother nor education of father has a significant effect on infant mortality in rural Nepal.     

Reproductive patterns and thalassaemia major

This study investigated the effect of the diagnosis of transfusion-dependent homozygous beta-thalassemia on subsequent parental reproductive patterns in 44 families in New South Wales. The results indicate a shift over time from parental risk-taking (either consciously or in ignorance of the implications of the diagnosis) to premature curtailment of reproduction to the likelihood of attaining birth expectations through antenatal diagnosis. 67% of families with both of their 1st 2 children affected by thalassemia major had additional children, compared with 38% of those where the 1st child was affected and the 2nd child was unaffected and 37% of families where the 1st child was unaffected and the 2nd child was affected. Overall, 48% of mothers of children with thalassemia major had as many children as they had expected at the time of marriage, 13% had more, and 39% had fewer children. The mothers of older children were less likely to have had the planned number of births than those of children born more recently. The value of antenatal diagnosis to couples at risk of thalassemia appears to have been to enable them to meet or almost meet their birth expectations.     

Fertility trends in Singapore

In 1966, the Singapore National Family Planning and Population Program established the goal of reaching replacement fertility by 1990 and zero population growth by the year 2030. To achieve this goal, the government relied on a series of incentives and disincentives to discourage births above the 3rd birth order, including tax relief for the 1st 3 children only, paid medical leave for women undergoing sterilization after the 3rd or subsequent birth, monetary stipends in some cases where the mother is sterilized after the 1st or 2nd birth, and increasing accouchement charges for increasing birth orders. Also important to demographic planning were liberalization of Singapore's abortion legislation and more aggressive promotion of contraception. As a result of these efforts, Singapore's crude birth rate has declined from 29.5/1000 population in 1965 to 16.6/1000 in 1985. Also observed have been dramatic declines in infant mortality in this same period, from 26.2/1000 live births to 9.3/1000, and in maternal mortality, from 52/100,000 live births to 10/100,000. In 1985, 42% of total births were to women in the 25-29-year age group. The numbers of 4th and later births fell by 90% between 1966 and 1985. The total fertility rate has declined from 4.6/woman in 1965 to 3.1 in 1970 to 1.6 in 1986. Below replacement level fertility was achieved in 1975, in part because of government policy but also as a result of cultural and socioeconomic factors such as increasing female labor force participation rates, a break-up of the extended family system, a rise in the age at 1st marriage, and rises in educational attainment. The drop in fertility was contributed mainly by the higher socioeconomic class, more affluent, and educated Singaporeans. Thus, in 1981, the government introduced certain pronatalist policies and incentives to encourage better educated women to produce more children, e.g., tax relief and the elimination of monetary incentives to sterilization acceptors above a median income level.     

Month of birth, socioeconomic background and development in Swedish men

Season of birth has been shown to correlate with many aspects of somatic and mental disorders, development and social adaptation (so-called 'birth-date effects'). In a sample of young Swedish men, corresponding roughly to a one-year birth cohort, the results of intelligence tests, psychologists' ratings of psychological function, school achievement, body height, weight and self-reported health during childhood, were found to be correlated with month of birth, and--more strongly--father's socioeconomic status. The results were more favourable for men who were born during March-May (the period of highest birth rate), and whose fathers were of higher socioeconomic status, than for those born in November and December (the period of lowest birth rate), and whose fathers were in the lower socioeconomic group. It seems reasonable to conclude, from this study and previously reported findings, that these so-called 'birth-date effects' are determined by varying and often interacting biological and psychosocial factors. Among these factors, the light-induced entrainment of circadian and annual rhythms in the fetus and/or infant seems to be of pivotal importance. The organization of children into one-year age classes therefore produces an unfair lack of equality of possibilities.     

Development of the omasum in sheep

Data are presented on the histogenesis of the omasal mucosa in sheep from the 2.5 cm crown-rump (c-r) length fetus to the adult. 11 stages of fetal development, and 4 post-natal stages, were studies. The distribution of glycogen in the omasal epithelium was also studied. During fetal life the omasal epithelium was initially stratified cuboidal in type, but the superficial layers of cells became flattened in later stages of gestation. This epithelium became extremely thick by the late stages of fetal life, reaching a maximum of 358 micron, and consisting of greater than 20 layers of cells, in the 45 cm c-r fetus (approximatelay 140 days). After birth the epithelium became markedly reduced in thickness, being approximately 77 micron in the adult, and had differentiated into a cornified stratified squamous epithelium of the adult type by 12 weeks after birth. Glycogen was extremely abundant in the omasal epithelium of the 2.5 cm fetus, and declined gradually thereafter to be almost completely absent in post-natal specimens. 4 orders of laminae were present in the adult omasum, distributed in the seqeunce 1-4-3-4-2-4-3-4-1. The 1st order was already present in fetuses of 2.5 cm c-r length, with the 2nd, 3rd and 4th appearing by the 3.5, 5.5 and 11.0 cm stages, respectively. Initial stages in the development of conical papillae were first seen in 15.0 cm fetuses, but the development of these papillae was not completed until after birth.     

The role of parental investments for cognitive and noncognitive skill formation—Evidence for the first 11 years of life

This paper examines the impact of parental investments on the development of cognitive, mental and emotional skills during childhood using data from a longitudinal study, the Mannheim Study of Children at Risk, starting at birth. Our work offers three important innovations. First, we use reliable measures of the child's cognitive, mental and emotional skills as well as accurate measures of parental investments. The observed investments include parental health behaviour, playing and talking with the child, play materials, leisure activities and others. Second, we estimate latent factor models to account for unobserved characteristics of children. Third, we examine the skill development for girls and boys separately, as well as for children who were born with either organic or psychosocial risk. We find a decreasing impact of parental investments on cognitive and mental skills over time, while emotional skills seem to be unaffected by parental investments in childhood. Thus, inequality at birth persists during childhood. Since families are the main sources of education during the first years of life, our results have important implications for the quality of the parent-child relationship. Improving maternal health during pregnancy and parental investments in infancy can yield large benefits for cognitive and mental development later in childhood.     

Factors influencing prereproductive mortality in the isolated and preindustrial western Mediterranean population of La Alpujarra, 1900-1950

We study the effects of several variables on the prereproductive mortality pattern in the isolated and rural population of La Alpujarra, located on the western Mediterranean coast (southeast Spain), in the first half of the 20th century. The study is a retrospective analysis from a total sample of 2,200 deliveries, 2,085 of which were born alive and 171 of which did not survive to the 20th birthday. The potential influences of birthdate of children, twinning, firstborn, parental inbreeding, and sex on Alpujarran mortality were analyzed through logistic regression. Parity, family size, and birth interval effects were estimated through the difference between observed and expected mortality rates. In every case four age groups of mortality were considered because of the large influence of child growth: neonatal (less than 1 month of life), postneonatal infant (between 1 month and 1 year old), childhood (1-5 years old), and youth (5-20 years old). The Alpujarran prereproductive mortality pattern can be summarized as the result of three main risk factors: biodemographic, biomechanical, and social and health determinants. In general, every factor showed a decreased effect as children grew. The most significant determinants were birthdate of children, which is more related to increased mother's awareness of child care than to health improvement, and family size associated with decreasing alimentary resources as the sibling number increased. Male mortality was higher than female mortality in children older than 1 year but not for infant mortality, possibly as a result of a reproductive behavior favorable to males. Although firstborn status and twinning appeared associated with high mortality, maternal age and birth interval were related to low risk, but these influences always ceased after the first month of life. Parental inbreeding did not show any effect on infant, childhood, or youth mortality.     

Socioeconomic determinants of age at first marriage in Bangladesh

Using data from the 1976 Bangladesh Fertility Survey, multiple classification analysis was used to evaluate the effect of socioeconomic factors on age at 1st marriage. The independent variables considered were education, childhood and current residence, religion, work status before marriage, and husband's childhood residence, education, and occupation. Analysis was carried out for the total sample as well as for 3 birth cohorts of approximately equal size: 1) those born before 1940, 2) those born between 1940-50, and 3) those born after 1950. Of all the included variables, women's education has the strongest influence on the variation of age at 1st marriage. For all ever-married women, the mean age at marriage for women with primary education is 13.4 years, 0.9 years higher than for women with no education (12.5 years), and 1.2 years lower than for women with a high school education or beyond (14.6 years). Difference in means for cohorts indicate a gradually increasing influence of education on people's decision in marriage. Husband's education does not appear to be as important. Childhood residence has, directly and indirectly, a strong influence in marriage age. Among other factors, women's premarital work participation, as well as region and husband's occupation, are important. Since women's education, childhood residence, and work participation are the strongest socioeconomic variables affecting marriage age, the modernizing influences of education, urbanization, and female work participation should have an effect on the marriage pattern; this effect is consistent with that observed in other societies.     

Covariates of age at first birth in Guyana: a hazards model analysis

Analysis of data from the Guyana Fertility Survey on the trends and covariates of age at 1st birth among various birth cohorts of women ever in union indicates that an early entry into union is associated with young age at 1st birth and higher number of children born. Multivariate analysis showed that women with higher education, urban residence, and entry into 1st birth compared to others, and that young women are delaying their 1st birth for longer durations than older women. Work status of women before 1st birth and the starting age of union seem to be the 2 major contributory factors for age at 1st birth. Noticeably, the role of education has changed and is now more significant among younger cohorts than among older ones for 1st birth timing.     

Marriage structure and contraception in Niger

Analysis of the 1992 Niger Demographic and Health Survey showed that although roughly two-thirds of both polygamous and monogamous women approve of birth control, polygamous wives are less likely than monogamous wives to discuss family size or birth control with their husband or to plan on using birth control. The study suggests that characteristics of polygamous couples have caused polygamous women to be more resistant to birth control use than monogamous women. The polygamous women tended to be married to older men who had not gone to primary school and who desired more children than monogamous husbands. The influence of marital structure is not significantly associated with intention to use birth control when the husband's age and the wife's ideal number of children were controlled for in the multivariate logistic regression model suggesting that background social factors may be more influential. In fact, educational level and age at first marriage were significantly associated with attitudes towards birth control and also with marital structure.     

Individual variation and longitudinal pattern of genome-wide DNA methylation from birth to the first two years of life

Prenatal development and early childhood are critical periods for establishing the tissue-specific epigenome, and may have a profound impact on health and disease in later life. However, epigenomic profiles at birth and in early childhood remain largely unexplored. The focus of this report is to examine the individual variation and longitudinal pattern of genome-wide DNA methylation levels from birth through the first two years of life in 105 Black children (59 males and 46 females) enrolled at the Boston Medical Center. We performed epigenomic mapping of cord blood at birth and venous blood samples from the same set of children within the first two years of life using Illumina Infinium Humanmethylation27 BeadChip. We observed a wide range of inter-individual variations in genome-wide methylation at each time point including lower levels at CpG islands, TSS200, 5′UTR and 1st Exon locations, but significantly higher levels in CpG shores, shelves, TSS1500, gene body and 3′UTR. We identified CpG sites with significant intra-individual longitudinal changes in the first two years of life throughout the genome. Specifically, we identified 159 CpG sites in males and 149 CpG sites in females with significant longitudinal changes defined by both statistical significance and magnitude of changes. These significant CpG sites appeared to be located within genes with important biological functions including immunity and inflammation. Further studies are needed to replicate our findings, including analysis by specific cell types, and link those individual variations and longitudinal changes with specific health outcomes in early childhood and later life.     

Individual variation and longitudinal pattern of genome-wide DNA methylation from birth to the first two years of life

Prenatal development and early childhood are critical periods for establishing the tissue-specific epigenome, and may have a profound impact on health and disease in later life. However, epigenomic profiles at birth and in early childhood remain largely unexplored. The focus of this report is to examine the individual variation and longitudinal pattern of genome-wide DNA methylation levels from birth through the first two years of life in 105 Black children (59 males and 46 females) enrolled at the Boston Medical Center. We performed epigenomic mapping of cord blood at birth and venous blood samples from the same set of children within the first two years of life using Illumina Infinium Humanmethylation27 BeadChip. We observed a wide range of inter-individual variations in genome-wide methylation at each time point including lower levels at CpG islands, TSS200, 5′UTR and 1st Exon locations, but significantly higher levels in CpG shores, shelves, TSS1500, gene body and 3′UTR. We identified CpG sites with significant intra-individual longitudinal changes in the first two years of life throughout the genome. Specifically, we identified 159 CpG sites in males and 149 CpG sites in females with significant longitudinal changes defined by both statistical significance and magnitude of changes. These significant CpG sites appeared to be located within genes with important biological functions including immunity and inflammation. Further studies are needed to replicate our findings, including analysis by specific cell types, and link those individual variations and longitudinal changes with specific health outcomes in early childhood and later life.     

Childhood predictors of self reported chronic fatigue syndrome/myalgic encephalomyelitis in adults: national birth cohort study

Objective To study childhood risk factors for chronic fatigue syndrome in adult life.Design Examination of data from the 1970 British birth cohort.Participants 16 567 babies born 5-11 April 1970, followed up at 5, 10, 16, and 29-30 years.Main outcome measures Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) identified by self report at age 30 years. Data from childhood from questionnaires given to parents and teachers. Maternal mental health assessed with the malaise inventory.Results 93 (0.8%, 95% confidence interval 0.7 to 1.0) of 11 261 participants reported ever having CFS/ME, and 48 (0.4%, 0.3 to 0.6) had the condition currently. Higher risk of CFS/ME was associated with having a limiting longstanding condition in childhood (odds ratio 2.3, 1.4 to 3.9), female sex (2.3, 1.4 to 2.6), and high social class in childhood (2.2, 1.4 to 3.5). Higher levels of exercise in childhood were associated with lower risk (0.5, 0.2 to 0.9). Maternal psychological disorder, psychological problems in childhood, birth weight, birth order, atopy, obesity, school absence, academic ability, and parental illness were not associated with risk of CFS/ME.Conclusions We identified no association between maternal or child psychological distress, academic ability, parental illness, atopy, or birth order and increasing risk of lifetime CFS/ME. Sedentary behaviour increased the risk.     

Incidence of leukaemia and other cancers in birth and schools cohorts in the Dounreay area.

OBJECTIVE--To determine whether a raised incidence of leukaemia in the Dounreay area occurred in children born to local mothers (birth cohort) or in those who moved to the area after birth (schools cohort) and also whether any cases of cancer have occurred in children born near Dounreay who may have moved elsewhere. DESIGN--Follow up study. SETTING--Dounreay area of Caithness, Scotland. SUBJECTS--4144 children born in the area in the period 1969-88 and 1641 children who attended local schools in the same period but who had been born elsewhere. MAIN OUTCOME MEASURES--Cancer registration records linked to birth and school records with computerised probability matching methods. RESULTS--Five cancer registrations were traced from the birth cohort compared with 5.8 expected on the basis of national rates (observed to expected ratio 0.9, 95% confidence interval 0.3 to 2.0). All five cases were of leukaemia (2.3, 0.7 to 5.4). In the schools cohort three cases were found (2.1, 0.4 to 6.2), all of which were of leukaemia (6.7, 1.4 to 19.5). All eight children were resident in the Dounreay area at the time of diagnosis; thus no cases were found in children who were born in or had attended school in the study area but who subsequently moved away. CONCLUSION--The raised incidence of leukaemia in both the birth and schools cohorts suggests that place of birth is not a more important factor than place of residence in the series of cases of leukaemia observed near Dounreay area.