Poverty,prenatal care,and infant health in Puerto Rico

Using data from a survey administered to a representative sample of mothers who gave birth in Puerto Rico in 1994-95, we investigate whether prenatal care and infant health outcomes are associated with family poverty and neighborhood poverty. The results show that infant health outcomes are unrelated to both family poverty and neighborhood poverty, despite the association of family poverty with the adequacy of prenatal care and the content of prenatal care. However, the poverty paradigm does receive some support using measures of participation in government programs that serve the low-income population. Women who rely on the government to fund their medical care are more likely than women who rely on private health insurance to have an infant death. They are also less likely to receive the highest levels of prenatal care. Nonetheless, targeted government programs can have an ameliorative impact. The analysis shows that participants in the Women, Infants, and Children (WIC) program are more likely than non-participants to receive superior levels of prenatal care and are less likely to have negative infant health outcomes.     

Low-birth-weight effects of demographic and socioeconomic variables and prenatal care in Pima County,Arizona.

Low birth weight is the major determinant of infant mortality. Continuing declines in infant mortality in the United States are due to the use of neonatal intensive care services; less progress has been made toward preventing low birth weight. I examined how the demographic, socioeconomic, and health services use variables affected rates of low birth weights in Pima County, Arizona, in 1985. Women at greatest risk of having the smallest infants were those younger than 21 years and those with fewer than 6 prenatal visits. Nulliparous women with fewer than 6 prenatal visits showed a still greater risk of having an infant of low birth weight. Women without medical insurance coverage had babies with the lowest mean birth weights, as well as significantly fewer prenatal visits. As the number of uninsured in the United States increases, the effect of lack of insurance among pregnant women becomes increasingly important. To prevent low-weight births, comprehensive maternity care services must be available to all pregnant women regardless of ability to pay.     

Underlying and proximate determinants of diarrhoea-specific infant mortality rates among municipalities in the state of Céara, north-east Brazil: an ecological study

This ecological study examines the variations in diarrhoea-specific infant mortality rates among municipalities in the State of Ceará, north-east Brazil, using data from a community health workers' programme. Diarrhoea is the main cause of postneonatal deaths in Ceará, and diarrhoea mortality rates vary substantially among municipalities, from 7 to 50 per thousand live births. To determine the inter-relationships between potential predictors of diarrhoea-specific infant mortality, eleven variables were classified into proximate determinants (i.e. adequate weight gain and exclusive breast-feeding in first 4 months) and underlying determinants (i.e. health services and socioeconomic variables). The health services variables included percentage with prenatal care up-to-date, participation in growth monitoring and immunization up-to-date, while the socioeconomic factors included female illiteracy rate, per capita gross municipality product and percentage of households with low income, percentage of households with inadequate water supply and inadequate sanitation, and urbanization. Using linear regression analysis variables were included from each group to build regression models. The significant determinants of variability in diarrhoea-specific infant mortality between municipalities were prevalence of infants exclusively breast-feeding, percentage of infants with adequate weight gain, percentage of pregnant women with prenatal care up-to-date, female illiteracy rate and inadequate water supply. These findings suggest that community-based promotion of exclusive breast-feeding in the first 4 months and care-giving behaviours that prevent weight faltering, including weaning practices and feeding during and following diarrhoea episodes, may further reduce municipality-level diarrhoea-specific mortality. Primary heath care strategies addressing these two proximate determinants provide only a partial solution to reducing diarrhoeal disease mortality. Improvements in municipal health services (prenatal care) and socioeconomic status variables, including water supply and maternal education, can also contribute to reduction of infant mortality due to diarrhoea. These results may be used by government health officials to set priorities by considering not only the strength of the association between selected risk factors and diarrhoea mortality rates, but also the prevalence of the risk factors being considered at the municipality level. Finally, the methods used are applicable to other settings with community-based primary health care decentralized to the state or municipal level.     

Birth defects in India: Hidden truth,need for urgent attention

Birth defects (structural, functional and metabolic disorder present from birth, may be diagnosed later) rising up as an important cause of infant mortality even in developing countries where infant mortality has been reduced to much extent. Seventy percent of birth defects are preventable through the application of various cost effective community genetic services.Indian people are living in the midst of risk factors for birth defects, e.g., universality of marriage, high fertility, large number of unplanned pregnancies, poor coverage of antenatal care, poor maternal nutritional status, high consanguineous marriages rate, and high carrier rate for hemoglobinopathies. India being the second most populous country with a large number infant born annually with birth defects should focus its attention on strategies for control of birth defects. Many population based strategies such as iodization, double fortification of salt, flour fortification with multivitamins, folic acid supplementation, periconceptional care, carrier screening and prenatal screening are some of proven strategies for control of birth defects. Strategies such as iodization of salt in spite of being initiated for a long time in the past do have a very little impact on its consumption (only 50% were using iodized salt). Community genetic services for control of birth defects can be easily flourished and integrated with primary health care in India because of its well established infrastructure and personnel in the field of maternal and child health care. As there is wide variation for infant mortality rate (IMR) in different states in India, so there is a need of deferential approach to implement community genetic services in states those had already achieved national goal of IMR. On the other hand, states those have not achieved the national goal on IMR priority should be given to management of other causes of infant mortality.     

Maternal, neonatal and community factors influencing neonatal mortality in Brazil

Child mortality (the mortality of children less than five years old) declined considerably in the developing world in the 1990s, but infant mortality declined less. The reductions in neonatal mortality were not impressive and, as a consequence, there is an increasing percentage of infant deaths in the neonatal period. Any further reduction in child mortality, therefore, requires an understanding of the determinants of neonatal mortality. 209,628 birth and 2581 neonatal death records for the 1998 birth cohort from the city of S?o Paulo, Brazil, were probabilistically matched. Data were from SINASC and SIM, Information Systems on Live Births and Deaths of Brazil. Logistic regression was used to find the association between neonatal mortality and the following risk factors: birth weight, gestational age, Apgar scores at 1 and 5 minutes, delivery mode, plurality, sex, maternal education, maternal age, number of prior losses, prenatal care, race, parity and community development. Infants of older mothers were less likely to die in the neonatal period. Caesarean delivery was not found to be associated with neonatal mortality. Low birth weight, pre-term birth and low Apgar scores were associated with neonatal death. Having a mother who lives in the highest developed community decreased the odds of neonatal death, suggesting that factors not measured in this study are behind such association. This result may also indicate that other factors over and above biological and more proximate factors could affect neonatal death.     

Evidence of compliance with and effectiveness of guidelines for noninvasive prenatal testing in China: a retrospective study of 189,809 cases

In China,the medical guidelines recommend performing noninvasive prenatal testing (NIPT) with caution for pregnant women aged 35 years or older.However,the Mother and Child Health Care Law suggests that all primiparous women whose age is older than 35 years undergo prenatal diagnosis.These two inconsistent suggestions/recommendations have made obstetricians confused about whether to offer NIPT to these older pregnant women.To face this issue and find out the solution we performed a retrospective study of 189,809 NIPT samples collected from 28 provincial-leveled administrative units in China.Of 1,564women with high-risk pregnancies who underwent NIPT,459 (29.3%) did not participate in follow-up.The compound sensitivity and specificity of NIPT for trisomies 21,18 and 13 detection was 99.1%(95%CI,98.0%-99.6%) and 99.9%(95%CI,98.8%-99.9%),respectively.In secundiparous women,NIPT showed high sensitivity and specificity similar to that in primiparous women.The observed risk for trisomies 21 and 18 significantly increased when the maternal age was 39 and older.After the publication of the current NIPT policy,the follow-up rate at our center was 97.9%;however,a large number of women are not in maternal and infant care networks nationwide,and that makes the follow-up rate outside our center relatively low.Our study shows that to balance the prevention of major aneuploidies and the limited resources for prenatal diagnosis,the cut-off age of 35for invasive prenatal diagnosis might be unnecessary.Although the NIPT guidelines are well written,how to practice it effectively,especially in less industrialized areas,is worth discussing.     

Effect of maternal zinc deficiency on offspring health: The epigenetic impact

BackgroundZinc deficiency is associated with adverse effects on maternal health and pregnancy outcomes. These consequences have been reported over the years from zinc supplementation trials and observational studies whereby outcomes of maternal, foetal and infant health were measured. Owing to the importance of zinc in the functions of epigenetic enzymes, pre-clinical studies have shown that its deficiency could disrupt biological activities that involve epigenetic mechanisms in offspring. Thus, this review assessed the link between epigenetics and the effects of maternal zinc deficiency on the offspring’s health in animal studies.MethodsResearch articles were retrieved without date restriction from PubMed, Web of Science, ScienceDirect, and Google Scholar databases, as well as reference lists of relevant articles. The search terms used were “zinc deficiency”, “maternal zinc deficiency”, “epigenetics”, and “offspring.” Six studies met the eligibility criteria and were reviewed.ResultsAll the eligible studies reported maternal zinc deficiency and observed changes in epigenetic markers on the progeny during prenatal and postnatal stages of development. The main epigenetic markers reported were global and gene specific methylation and/ or acetylation. The epigenetic changes led to mortality, disruption in development, and risk of later life diseases.ConclusionMaternal zinc deficiency is associated with epigenetic modifications in offspring, which induce pathologies and increase the risk of later life diseases. More research and insight into the epigenetic mechanisms could spring up new approaches to combat the associated disease conditions.     

Explaining variation in maternal care in a cooperatively breeding mammal

Because of the necessity of lactation, mammalian mothers must perform at least a minimum amount of infant care. In cooperatively breeding species, other group members aid in all other aspects of infant care. However, some mothers continue to carry and nurse their infants more than others. The golden lion tamarin, Leontopithecus rosalia, is a small, communally breeding primate in the family Callitrichidae. We studied hormonal, individual, historical and social factors hypothesized to contribute to variation in levels of maternal care. We used neonatal weight as a measure of prenatal care, and carrying and nursing as measures of postnatal care. Greater neonatal weight was associated with smaller litter size, lower prepartum levels of oestrogen conjugates, and higher prepartum cortisol levels. Higher rates of carrying during weeks 2 and 3 were associated with higher maternal weight, larger litter size and smaller numbers of helpers per infant. Higher rates of nursing in weeks 2 and 3 were predicted by smaller group size and provisioning of the mother. The most important factors affecting postnatal maternal care were maternal weight, group size, litter size and provisioning status of the mother. Thus, females that display higher levels of maternal care do so either because they have to (they have fewer helpers) or because they can (they are in better condition).     

Prenatal diagnosis using fetal cells from the maternal circulation.

All current methods of fetal karyotyping are invasive and carry a definite, albeit small, procedure-related risk. Because of this and testing costs, only women older than 35 years who have a greater risk for fetal aneuploidy are currently offered prenatal testing. But this detects only 20% to 25% of fetuses with Down syndrome. It would be a tremendous advance to find a noninvasive technique for prenatal diagnosis that carries no procedure-related risk and could be offered to all pregnant women. We describe a possible technique for noninvasive prenatal diagnosis that aims to identify fetal cells in the peripheral maternal circulation and successfully garner them for prenatal testing. Early attempts at fetal karyotyping were hampered by inaccurate diagnostic methods and cumbersome cell-counting techniques. Today, improved capabilities of identifying and enriching for fetal cells, coupled with sensitive methods of analysis such as the polymerase chain reaction, bring renewed enthusiasm to this task. Many technical issues, as well as serious questions regarding the test''s utility, still exist, however, and must be explored and answered before the capture of fetal cells in the maternal circulation translates into reality for noninvasive prenatal diagnosis.     

Prenatal care demand and its effects on birth outcomes by birth defect status in Argentina

Our objective was to identify determinants of prenatal care demand and evaluate the effects of this demand on low birth weight and preterm birth. Delay in initiating prenatal care was modeled as a function of pregnancy risk indicators, enabling factors, and regional characteristics. Conditional maximum likelihood (CML) estimation was used to model self-selection into prenatal care use when estimating its effectiveness. Birth registry data was collected post delivery on infants with and without common birth defects born in 1995-2002 in Argentina using a standard procedure. Several maternal health and fertility indicators had significant effects on prenatal care use. In the group without birth defects, prenatal care delay increased significantly LBW and preterm birth when accounting for self-selection using the CML model but not in the standard probit model. Prenatal care was found to be ineffective on average in the birth defect group. The self-selection of higher risk women into earlier initiation of prenatal care resulted in underestimation of prenatal care effectiveness when using a standard probit model with several covariates. Large improvements in birth outcomes are suggested with earlier initiation of prenatal care for pregnancies uncomplicated with birth defects in Argentina, implying large opportunity costs from the long waiting time observed in this sample (about 17 weeks on average). The suggested ineffectiveness for pregnancies complicated with common birth defects deserves further research.     

Identifying the intergenerational effects of the 1959–1961 Chinese Great Leap Forward Famine on infant mortality

Using the 1959–1961 Chinese Great Leap Forward Famine as a natural experiment, this study examines the relationship between mothers’ prenatal exposure to acute malnutrition and their children's infant mortality risk. According to the results, the effect of mothers’ prenatal famine exposure status on children's infant mortality risk depends on the level of famine severity. In regions of low famine severity, mothers’ prenatal famine exposure significantly reduces children's infant mortality, whereas in regions of high famine severity, such prenatal exposure increases children's infant mortality although the effect is not statistically significant. Such a curvilinear relationship between mothers’ prenatal malnutrition status and their children's infant mortality risk is more complicated than the linear relationship predicted by the original fetal origins hypothesis but is consistent with the more recent developmental origins of health and disease theory.     

Postpartum depression: Etiology,treatment and consequences for maternal care

This article is part of a Special Issue “Parental Care”. Pregnancy and postpartum are associated with dramatic alterations in steroid and peptide hormones which alter the mothers' hypothalamic pituitary adrenal (HPA) and hypothalamic pituitary gonadal (HPG) axes. Dysregulations in these endocrine axes are related to mood disorders and as such it should not come as a major surprise that pregnancy and the postpartum period can have profound effects on maternal mood. Indeed, pregnancy and postpartum are associated with an increased risk for developing depressive symptoms in women. Postpartum depression affects approximately 10–15% of women and impairs mother–infant interactions that in turn are important for child development. Maternal attachment, sensitivity and parenting style are essential for a healthy maturation of an infant's social, cognitive and behavioral skills and depressed mothers often display less attachment, sensitivity and more harsh or disrupted parenting behaviors, which may contribute to reports of adverse child outcomes in children of depressed mothers. Here we review, in honor of the “father of motherhood”, Jay Rosenblatt, the literature on postnatal depression in the mother and its effect on mother–infant interactions. We will cover clinical and pre-clinical findings highlighting putative neurobiological mechanisms underlying postpartum depression and how they relate to maternal behaviors and infant outcome. We also review animal models that investigate the neurobiology of maternal mood and disrupted maternal care. In particular, we discuss the implications of endogenous and exogenous manipulations of glucocorticoids on maternal care and mood. Lastly we discuss interventions during gestation and postpartum that may improve maternal symptoms and behavior and thus may alter developmental outcome of the offspring.     

Assessment and Evaluation of the High Risk Neonate: The NICU Network Neurobehavioral Scale

There has been a long-standing interest in the assessment of the neurobehavioral integrity of the newborn infant. The NICU Network Neurobehavioral Scale (NNNS) was developed as an assessment for the at-risk infant. These are infants who are at increased risk for poor developmental outcome because of insults during prenatal development, such as substance exposure or prematurity or factors such as poverty, poor nutrition or lack of prenatal care that can have adverse effects on the intrauterine environment and affect the developing fetus. The NNNS assesses the full range of infant neurobehavioral performance including neurological integrity, behavioral functioning, and signs of stress/abstinence. The NNNS is a noninvasive neonatal assessment tool with demonstrated validity as a predictor, not only of medical outcomes such as cerebral palsy diagnosis, neurological abnormalities, and diseases with risks to the brain, but also of developmental outcomes such as mental and motor functioning, behavior problems, school readiness, and IQ. The NNNS can identify infants at high risk for abnormal developmental outcome and is an important clinical tool that enables medical researchers and health practitioners to identify these infants and develop intervention programs to optimize the development of these infants as early as possible. The video shows the NNNS procedures, shows examples of normal and abnormal performance and the various clinical populations in which the exam can be used.     

Chikotsa--secrets, silence, and hiding: social risk and reproductive vulnerability in central Mozambique

In this article, I examine pregnancy narratives and patterns of reproductive health seeking among women of fertile age in central Mozambique. I map the interplay between gendered economic marginalization, maternal risk perceptions, and pregnancy management strategies. By interpreting my data in light of Shona illness theories, I illuminate the ways that embodied experiences of reproductive vulnerability, risk perceptions, and social inequalities are linked: women attribute the most serious maternal complications to human- or spirit-induced reproductive threats of witchcraft and sorcery. This construction of reproductive vulnerability as social threats related to material and social competition significantly influences prenatal health seeking. Data reveal the structural and cognitive gap between biomedical constructions of risk and lay social threat perceptions. Plural health care systems are strategically utilized by women seeking to minimize both social and biological harm. On-the-ground ethnography shows that maternal health initiatives must take this plurality into full and accommodative account to achieve viable improvements in reproductive care and outcomes.     

Case fatality among infants with congenital malformations by lethality

OBJECTIVE: Infant mortality rates continue to show that congenital anomalies are the leading cause of infant death in the United States. However, studies of factors contributing to increased mortality across different types of congenital anomalies have been limited. The objective of this study was to assess whether the likelihood of infant mortality varied by maternal race and ethnic group while considering the severity of the birth defect. METHODS: A retrospective cohort analysis was conducted using data from Colorado's statewide, population-based birth defects surveillance system (CRCSN). The cohort included infants, born between 1995 and 2000 to Colorado resident mothers, who were diagnosed with major congenital malformations stratified by degree of lethality. Multiple logistic regression was performed for each level of lethality, and included the following potential explanatory variables: maternal race/ethnicity, clinical gestation, birth weight, maternal education level, maternal age, and sex of child. RESULTS: Within the low/very low lethality cohort, maternal race/ethnicity of Black/non-Hispanic was associated with increased risk of infant mortality, OR 2.81 (1.41-5.19), as were low and very low birth weight, OR 2.21 (1.12-4.04) and 19.31 (11.84-31.01), respectively. Maternal race/ethnicity was not a significant risk factor in either high or very high lethality groups; however, the interaction between birth weight and gestational age significantly increased the risk of mortality. CONCLUSIONS: Through the use of statewide, population-based birth defects surveillance data, a disparity in infant mortality has been identified in a specific subset of the population that could be investigated further and targeted for prevention activities.     

A different disease: HIV/AIDS and health care for women in poverty

The goal of this paper is to demonstrate that HIV/AIDS for poor women is a qualitatively different disease than the one first defined in the United States in the 1980s. HIV/AIDS for poor women is not a new disease; it is only another life-threatening condition which parallels serious health problems already experienced by these populations. A time-honored and broad continuum of disease and death for poor women is linked to such factors as poverty, self-medication, infant morbidity, infant mortality and cervical cancer. The programmatic responses to HIV/AIDS in poor women have been grafted onto existing services established by and for homosexual men or onto the obstetrical-gynecological and prenatal systems already in place. Furthermore, the primary socio-psychological mechanisms of denial and dependency that characterize poor women are far more salient than notions of risk-taking or sexual lifestyles. These conclusions lead to somber predictions for the course of the epidemic and the prognosis for treatment and care for poor women with HIV.     

Attitudes Toward Weight Gain in Pregnancy

Recently, there has been increased interest in the influence of maternal prenatal nutrition on the course and outcome of pregnancy. Evidence has accumulated that a woman''s weight before pregnancy and the weight gained during pregnancy directly affect infant birth weight, incidence of neonatal mortality, and growth and development of the infant during the first year of life. Although recent recommendations for weight gain in pregnancy have been liberalized, a survey of 195 pregnant women who had prenatal visits in both clinic and private offices showed deficiencies in their understanding of the subject. Some 37 percent of women believed they should gain 20 pounds (9 kg) or less during pregnancy. Eight percent admitted to dieting before at least one antenatal visit and 54 percent thought their doctor would not be concerned about too little weight gained during pregnancy. This suggests that many women and some doctors are still ignorant of current concepts of proper nutrition during pregnancy. Apparently, increased lay and professional educational efforts are needed.     

Mink with Divergent Activity Levels have Divergent Reproductive Strategies

Stable individual differences in activity levels within populations have been linked to differences in reproductive rate or parental care in several species, including American mink (Neovison vison). Fur‐farmed mink are good models for studying such effects because they yield large sample sizes and readily allow investigations into maternal behaviour, reproductive success, offspring performance and the relationships between these factors. On farms, very inactive individuals generally have smaller litters, and this held true in our study populations. We tested two competing hypotheses to explain this: (1) inactive individuals are failing to cope with a challenging environment and experiencing chronic stress and/or depression‐like ‘apathy’; this predicts female‐skewed litters, poorer maternal care, higher infant mortality and poorer infant growth and (2) inactive individuals do not have reduced fitness but instead employ an alternative adaptive reproductive strategy, trading off offspring quantity for quality; this predicts enhanced maternal care, reduced infant mortality and enhanced infant growth. Inactive females’ kits, especially their sons, grew faster than active females’, even after statistically controlling for litter size; and by 21 d, inactive and active dams’ litters no longer differed in total biomass, despite the former’s smaller litter sizes. In kit retrieval tests, inactive females were faster than active dams to reach their sons (as well as more likely to contact their sons than their daughters: a bias towards male kits not evident in the active dams). Furthermore, kit growth rates and dam latencies to touch them co‐varied, suggesting the existence of consistent differences in maternal style across inactive and active dams. Hypothesis 2 was thus supported: inactive females favour offspring quality over quantity, investing more resources in fewer kits, particularly males. This potentially boosts their sons’ adult fitness. More broadly for laboratory‐based studies, possible ‘captivity effects’ on the fitness correlates of activity and other personality traits are discussed.     

Focus: The Science of Stress: Can Maternal Prenatal Self-Reported and Physiological Distress Predict Postnatal Caregiving Practices?

Maternal prenatal distress is associated with child outcomes, including health, neurocognitive, and socio-emotional development. Knowledge on underlying mechanisms is limited, yet relevant for prevention and intervention. This study investigated whether maternal prenatal distress predicts specific caregiving practices that are known for their effects on child outcomes. Caregiving practices studied were maternal caregiving quality and the initiation and course of breastfeeding and room-sharing. We hypothesized that more maternal prenatal distress would be associated with altered caregiving practices. Participants were 174 healthy mother-child dyads. During the 37^th week of pregnancy maternal self-reported distress was assessed using questionnaires, and physiological stress by collecting saliva cortisol. Maternal caregiving quality was observed in postnatal week 5 during infant bathing. Weekly diaries on breastfeeding and daily diaries on room-sharing were completed during the first 6 postnatal months. In a regression analysis, no associations between maternal prenatal distress and caregiving quality were found. Multilevel analyses indicated that maternal prenatal evening cortisol was positively related to the initiation of breastfeeding and room-sharing. Replications are warranted, but these results suggest that breastfeeding and room-sharing initiation may be part of a mechanism underlying links between maternal prenatal physiological stress and child outcomes. As other prenatal cortisol markers and self-reported distress were not found to be related to the caregiving practices, it is likely that alternative mechanisms (co-)exist in explaining links between maternal prenatal distress and child outcomes. Future replication research including child outcomes and (other) potential mechanisms will inform prevention and intervention programs fostering healthy pregnancies and child development.     

Perinatal mental health: a review of progress and challenges

Perinatal mental health has become a significant focus of interest in recent years, with investment in new specialist mental health services in some high‐income countries, and inpatient psychiatric mother and baby units in diverse settings. In this paper, we summarize and critically examine the epidemiology and impact of perinatal mental disorders, including emerging evidence of an increase of their prevalence in young pregnant women. Perinatal mental disorders are among the commonest morbidities of pregnancy, and make an important contribution to maternal mortality, as well as to adverse neonatal, infant and child outcomes. We then review the current evidence base on interventions, including individual level and public health ones, as well as service delivery models. Randomized controlled trials provide evidence on the effectiveness of psychological and psychosocial interventions at the individual level, though it is not yet clear which women with perinatal mental disorders also need additional support for parenting. The evidence base on psychotropic use in pregnancy is almost exclusively observational. There is little research on the full range of perinatal mental disorders, on how to improve access to treatment for women with psychosocial difficulties, and on the effectiveness of different service delivery models. We conclude with research and clinical implications, which, we argue, highlight the need for an extension of generic psychiatric services to include preconception care, and further investment into public health interventions, in addition to perinatal mental health services, potentially for women and men, to reduce maternal and child morbidity and mortality.