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1.  Use of the CRIB (clinical risk index for babies) score in prediction of neonatal mortality and morbidity. 
A prospective study of the outcome of care of a regional cohort of very low birthweight (< 1500 g) and very preterm (< 32 weeks) infants was carried out. Its aims were to assess the ability of the CRIB (clinical risk index for babies) score, rather than gestational age or birthweight, to predict mortality before hospital discharge, neurological morbidity, and length of stay, and to access CRIB score as an indicator of neonatal intensive care performance. 676 live births fulfilled the criteria and complete data were available for 643 (95%). Compared with gestation and birthweight, CRIB was better for the prediction of mortality, was as good for the prediction of morbidity, and was not as good for the prediction of length of stay. CRIB adjusted mortality did not demonstrate better performance in units providing the highest level of care. Either the CRIB score was not sensitive to performance or the level 3 hospitals in this study were performing badly. On the basis of this analysis purchasers and providers of neonatal intensive care cannot yet rely on the CRIB score as a performance indicator.
PMCID: PMC2528363  PMID: 7552593
2.  Indigenous Birth Outcomes in Australia, Canada, New Zealand and the United States – an Overview 
To review Indigenous infant mortality, stillbirth, birth weight, and preterm birth outcomes in Australia, Canada, New Zealand and the United States.
Systematic searches of published literature and a review and assessment of existing perinatal surveillance systems were undertaken. Where possible, within country comparisons of Indigenous to non-Indigenous birth outcomes are included.
Indigenous/non-Indigenous infant mortality rate ratios range from 1.6 to 4.0. Stillbirth rates, where data are available, are also uniformly higher for Indigenous people. In all four countries, the disparities in Indigenous/non-Indigenous infant mortality rate ratios are most marked in the post-neonatal period. With few exceptions, the rates of leading causes of infant mortality are higher among Indigenous infants than non-Indigenous infants within all four countries. In most cases, rates of small for gestational age and preterm birth were also elevated for Indigenous compared to non-Indigenous infants.
There are significant disparities in Indigenous/non-Indigenous birth outcomes in Australia, Canada, New Zealand and the United States. These Indigenous/non-Indigenous birth outcome disparities fit the criteria for health inequities, as they are not only unnecessary and avoidable, but also unfair and unjust.
PMCID: PMC3563669  PMID: 23390467 CAMSID: cams2716
Indigenous; birth outcomes; infant mortality; stillbirth; birth weight; and preterm birth; Canada; Australia; New Zealand; United States
3.  Delivery of maternal health care in Indigenous primary care services: baseline data for an ongoing quality improvement initiative 
Australia's Aboriginal and Torres Strait Islander (Indigenous) populations have disproportionately high rates of adverse perinatal outcomes relative to other Australians. Poorer access to good quality maternal health care is a key driver of this disparity. The aim of this study was to describe patterns of delivery of maternity care and service gaps in primary care services in Australian Indigenous communities.
We undertook a cross-sectional baseline audit for a quality improvement intervention. Medical records of 535 women from 34 Indigenous community health centres in five regions (Top End of Northern Territory 13, Central Australia 2, Far West New South Wales 6, Western Australia 9, and North Queensland 4) were audited. The main outcome measures included: adherence to recommended protocols and procedures in the antenatal and postnatal periods including: clinical, laboratory and ultrasound investigations; screening for gestational diabetes and Group B Streptococcus; brief intervention/advice on health-related behaviours and risks; and follow up of identified health problems.
The proportion of women presenting for their first antenatal visit in the first trimester ranged from 34% to 49% between regions; consequently, documentation of care early in pregnancy was poor. Overall, documentation of routine antenatal investigations and brief interventions/advice regarding health behaviours varied, and generally indicated that these services were underutilised. For example, 46% of known smokers received smoking cessation advice/counselling; 52% of all women received antenatal education and 51% had investigation for gestational diabetes. Overall, there was relatively good documentation of follow up of identified problems related to hypertension or diabetes, with over 70% of identified women being referred to a GP/Obstetrician.
Participating services had both strengths and weaknesses in the delivery of maternal health care. Increasing access to evidence-based screening and health information (most notably around smoking cessation) were consistently identified as opportunities for improvement across services.
PMCID: PMC3066246  PMID: 21385387
4.  Birthweight, preterm birth and perinatal mortality: A comparison of black babies in Tanzania and the USA 
Adverse conditions in Africa produce some of the highest rates of infant mortality in the world. Fetal growth restriction and preterm delivery are commonly regarded as major pathways through which conditions in the developing world affect infant survival. The aim of this article was to compare patterns of birthweight, preterm delivery, and perinatal mortality between black people in Tanzania and the USA.
Registry-based study.
Referral hospital data from North Eastern Tanzania and US Vital Statistics.
Consisted of 14 444 singleton babies from a hospital-based registry (1999–2006) and 3 530 335 black singletons from US vital statistics (1995–2000).
Main outcome measures
birthweight, gestational age and perinatal mortality.
Restricting to babies born with at least 500g, we compared birthweight, gestational age, and perinatal mortality (stillbirths and deaths in the first week) in the two study populations.
Perinatal mortality in the Tanzanian sample was 41/1000, compared with 10/100 among USA blacks. Tanzanian babies were slightly smaller on average (43g), but fewer were preterm (before 37 weeks) (10.0% vs 16.2%). Applying the USA weight-specific mortality rates to Tanzanian babies born at term suggested that birthweight does not play a role in their increased mortality relative to USA blacks.
Higher mortality independent of birthweight and preterm delivery for Tanzanian babies, suggests the need to address the contribution of other pathways that can further reduce the excess perinatal mortality.
PMCID: PMC3655527  PMID: 21615361
birthweight; developing country; fetal development; perinatal mortality; preterm birth
5.  Primary birthing attendants and birth outcomes in remote Inuit communities—a natural “experiment” in Nunavik, Canada 
There is a lack of data on the safety of midwife-led maternity care in remote or indigenous communities. In a de facto natural “experiment”, birth outcomes were assessed by primary birthing attendant in two sets of remote Inuit communities.
A geocoding-based retrospective birth cohort study in 14 Inuit communities of Nunavik, Canada, 1989–2000: primary birth attendants were Inuit midwives in the Hudson Bay (1529 Inuit births) vs western physicians in Ungava Bay communities (1197 Inuit births). The primary outcome was perinatal death. Secondary outcomes included stillbirth, neonatal death, post-neonatal death, preterm, small-for-gestational-age and low birthweight birth. Multilevel logistic regression was used to obtain the adjusted odds ratios (aOR) controlling for maternal age, marital status, parity, education, infant sex and plurality, community size and community-level random effects.
The aORs (95% confidence interval) for perinatal death comparing the Hudson Bay vs Ungava Bay communities were 1.29 (0.63 to 2.64) for all Inuit births and 1.13 (0.48 to 2.47) for Inuit births at ≥28 weeks of gestation. There were no statistically significant differences in the crude or adjusted risks of any of the outcomes examined.
Risks of perinatal death were somewhat but not significantly higher in the Hudson Bay communities with midwife-led maternity care compared with the Ungava Bay communities with physician-led maternity care. These findings are inconclusive, although the results excluding extremely preterm births are more reassuring concerning the safety of midwife-led maternity care in remote indigenous communities.
PMCID: PMC2956754  PMID: 19286689 CAMSID: cams388
6.  A comparative review of Asian and British-born maternity patients in Bradford, 1974-8. 
The perinatal mortality rate for Asian babies born in Bradford during the five years 1974-8 was persistently higher than for babies born to United Kingdom mothers. A comparative review of 18 924 British indigenous and 6443 Asian immigrant maternity patients delivered in Bradford from 1974-8 demonstrated several differences between the two ethnic groups. Factors operating in favour of Asian women were fewer teenage mothers, lower rates of illegitimacy, and fewer smokers. On the other hand, a greater number of factors presented increased risks to Asian patients-more women aged over 35, lower social class, higher parity, shorter pregnancy intervals, previous perinatal deaths, shorter duration of antenatal care, anaemia, shorter gestations, more babies born without professional help, and more low-birthweight babies. Local health education programmes are now concentrating on encouraging expectant mothers to attend early and regularly for antenatal care, to breast-feed their babies, and to increase the interval between pregnancies to at least one year.
PMCID: PMC1052133  PMID: 7299333
7.  Preterm caesarean section in Nigerian obstetric practice. 
A retrospective study of cases of preterm caesarean section was carried out at the University of Nigeria Teaching Hospital between January 1985 and December 1989. A total of 1973 caesarean sections were performed; 167 (8%) of these were preterm sections. Most of the patients were "booked" (133 cases, 80%) while 34 patients (20%) were "unbooked." The most common indications for preterm caesarean sections were preeclampsia, placenta previa, and premature rupture of membranes. The perinatal and maternal mortality were high: 257 per 1000 and 11 per 1000, respectively. Timely hospital admission, better intrapartum care, and vaginal delivery of very low birthweight babies are suggested to reduce the incidence of preterm caesarean section and its attendant complications in our hospital practice.
PMCID: PMC2571830  PMID: 8107161
8.  Associations between perinatal interventions and hospital stillbirth rates and neonatal mortality 
Background: Previous studies suggest that high risk and low birthweight babies have better outcomes if born in hospitals with level III neonatal intensive care units. Relations between obstetric care, particularly intrapartum interventions and perinatal outcomes, are less well understood, however.
Objective: To investigate effects of obstetric, paediatric, and demographic factors on rates of hospital stillbirths and neonatal mortality.
Methods: Cross sectional data on all 65 maternity units in all Thames Regions, 1994–1996, covering 540 834 live births and stillbirths. Hospital level analyses investigated associations between staffing rates (consultant/junior paediatricians, consultant/junior obstetricians, midwives), facilities (consultant obstetrician/anaesthetist sessions, delivery beds, special care baby unit, neonatal intensive care unit cots, etc), interventions (vaginal births, caesarean sections, forceps, epidurals, inductions, general anaesthetic), parental data (parity, maternal age, social class, deprivation, multiple births), and birthweight standardised stillbirth rates and neonatal mortality.
Results: Unifactorial analyses showed consistent negative associations between measures of obstetric intervention and stillbirth rates. Some measures of staffing, facilities, and parental data also showed significant associations. Scores for interventional, organisational, and parental variables were derived for multifactorial analysis to overcome the statistical problems caused by high intercorrelations between variables. A higher intervention score and higher number of consultant obstetricians per 1000 births were both independently and significantly associated with lower stillbirth rates. Organisational and parental factors were not significant after adjustment. Only Townsend deprivation score was significantly associated with neonatal mortality (positive correlation).
Conclusions: Birthweight adjusted stillbirth rates were significantly lower in units that took a more interventionalist approach and in those with higher levels of consultant obstetric staffing. There were no apparent associations between neonatal death rates and the hospital factors measured here.
PMCID: PMC1721633  PMID: 14711857
9.  Influence of elective preterm delivery on birthweight and head circumference standards. 
We calculated new birthweight and head circumference centiles for boys and girls between 24 and 42 weeks' gestation from 20,713 singleton live births at our hospital between 1978 and 1984. Among the 803 babies born at or before 34 weeks' gestation, 28% were delivered electively for fetal problems; they were considerably lighter than babies born after spontaneous preterm labour. In contrast, they showed only a small deficit in head circumference, possibly due to a brain sparing effect in growth retarded infants. Electively delivered preterm infants cause a bias in birthweight and head circumference centiles and we recommend that these babies should be excluded when these centiles are calculated.
PMCID: PMC1778138  PMID: 3813633
10.  Risk adjusted and population based studies of the outcome for high risk infants in Scotland and Australia 
OBJECTIVES—To compare outcomes of care in selected neonatal intensive care units (NICUs) for very low birthweight (VLBW) or preterm infants in Scotland and Australia (study 1) and perinatal care for all VLBW infants in both countries (study 2).
DESIGN—Study 1: risk adjusted cohort study; study 2: population based cohort study.
SUBJECTS—Study 1: all 2621 infants of < 1500 g birth weight or < 31 weeks' gestation admitted to a volunteer sample of hospitals comprising eight of all 17 Scottish NICUs and six of all 12 tertiary NICUs in New South Wales and Queensland in 1993-1994; study 2: all 5986infants of 500-1499 g birth weight registered as live born in Scotland and Australia in 1993-1994.
MAIN OUTCOMES—Study 1: (a) hospital death; (b) death or cerebral damage, each adjusted for gestation and CRIB (clinical risk index for babies); study 2: neonatal (28 day) mortality.
RESULTS—Study 1. Data were obtained for 1628 admissions in six Australian NICUs, 775 in five Scottish tertiary NICUs, and 148 in three Scottish non-tertiary NICUs. Crude hospital death rates were 13%, 22%, and 22% respectively. Risk adjusted hospital mortality was about 50% higher in Scottish than in Australian NICUs (adjusted mortality ratio 1.46, 95% confidence interval (CI) 1.29 to 1.63,p < 0.001). There was no difference in risk adjusted outcomes between Scottish tertiary and non-tertiary NICUs. After risk adjustment, death or cerebral damage was more common in Scottish than Australian NICUs (odds ratio 1.9, 95% CI 1.5 to 2.5). Both these risk adjusted adverse outcomes remained more common in Scottish than Australian NICUs after excluding all infants < 28 weeks' gestation from the comparison. Study 2. Population based neonatal mortality in infants of 500-1499 g was higher in Scotland (20.3%) than Australia (16.6%) (relative risk 1.22, 95% CI 1.08 to 1.39, p = 0.002). In a post hoc analysis, neonatal mortality was also higher in England and Wales than in Australia.
CONCLUSIONS—Study 1: outcome was better in the Australian NICUs. Study 2: perinatal outcome was better in Australia. Both results may be consistent, at least in part, with differences in the organisation and implementation of neonatal care.

PMCID: PMC1721047  PMID: 10685984
11.  Impact of improved perinatal care on the causes of death. 
Archives of Disease in Childhood  1984;59(3):199-207.
A total of 440 perinatal deaths occurring in a maternity hospital over a 6 year period have been analysed clinically and pathologically. The decline in mortality could be attributed to a reduction in asphyxial deaths, lethal malformations, and macerated stillbirths. The establishment of a neonatal intensive care unit seemed to have been more successful in combating birth asphyxia than respiratory distress syndrome. Although the greatest reduction in perinatal mortality was in babies with birthweights between 1 and 1.5 kg, there was no decline in the deaths from hyaline membrane disease or intraventricular haemorrhage, or both. The most striking change was the drop in asphyxia as a cause of perinatal death which was independent of birth trauma. Earlier diagnosis of fetal distress with obstetric intervention and the establishment of the intensive care unit were seen as the main factors in this change, and their mutual dependence and evolution are emphasised.
PMCID: PMC1628555  PMID: 6538776
12.  Nurse staffing in relation to risk‐adjusted mortality in neonatal care 
To assess whether risk‐adjusted mortality in very low birthweight or preterm infants is associated with levels of nursing provision.
Prospective study of risk‐adjusted mortality in infants admitted to a random sample of neonatal units.
Fifty four UK neonatal intensive care units stratified by: patient volume; consultant availability; nurse:cot ratios.
A group of 2585 very low birthweight (birthweight <1500 g) or preterm (<31 weeks gestation) infants.
Main Outcome Measure
Death before discharge or planned deaths at home, excluding lethal malformations, after adjusting for initial risk 12 hours after birth using gestation at birth and measures of illness severity in relation to nursing provision calculated for each baby's neonatal unit stay.
A total of 57% of nursing shifts were understaffed, with greater shortages at weekends. Risk‐adjusted mortality was inversely related to the provision of nurses with specialist neonatal qualifications (OR 0.67; 95% CI 0.42 to 0.97). Increasing the ratio of nurses with neonatal qualifications to intensive care and high dependency infants to 1:1 was associated with a decrease in risk‐adjusted mortality of 48% (OR: 0.52, 95% CI: 0.33, 0.83).
Risk‐adjusted mortality did not differ across neonatal units. However, survival in neonatal care for very low birthweight or preterm infants was related to proportion of nurses with neonatal qualifications per shift. The findings could be used to support specific standards of specialist nursing provision in neonatal and other areas of intensive and high dependency care.
PMCID: PMC2675478  PMID: 17088341
13.  Periodontal diseases as an emerging potential risk factor for adverse pregnancy outcomes: A review of concepts 
Preterm birth is the leading perinatal problem with subsequent morbidity and mortality in developed as well as developing nations. Among the various possible environmental, genetic, demographic, psychosocial and obstetric risk factors responsible for premature labor, poor oral health with periodontal infection has also emerged as a potential and modifiable risk factor for preterm low birth weight babies. The infected periodontium is regarded as a reservoir for periodontopathic bacteria, mainly gram negative anaerobes that serve as a source of endotoxins and lipopolysaccharides, proinflammatory cytokines and prostaglandins that enhance uterine muscle contraction leading to preterm low birth weight. Also, the progression of periodontal disease during pregnancy appears to increase the fetal growth restriction, irrespective of baseline periodontal disease status. Thus, identification and treatment of periodontal disease should be considered an important intervention strategy as a part of prenatal care to reduce adverse pregnancy outcomes.
PMCID: PMC3939276  PMID: 24591987
Adverse pregnancy outcomes; periodontal diseases; preterm low birth weight
14.  Low birthweight, preterm, and small for gestational age babies in Scotland, 1981-1984. 
STUDY OBJECTIVE--The aim was to examine the effect of maternal age, gravidity, marital status, previous perinatal deaths, and parental social class on babies born low birthweight, preterm, and small for gestational age. DESIGN--The study used data on discharge summaries from all maternity hospitals in Scotland. SETTING--The study was based on all singleton deliveries in Scotland. PARTICIPANTS--The analysis involved information on 259,462 singleton babies born during the four years 1981-84 in Scotland. MEASUREMENTS AND MAIN RESULTS--Previous perinatal death was found to be the strongest predictor for both preterm and low birthweight. Single mothers were at particularly high risk of having a small for gestational age baby and those who were previously married of having a preterm baby. Women aged less than 20 years old, those over 34 years old, nulligravidae, and those of parity 3 or more were also at increased risk of adverse pregnancy outcome. Mothers and fathers in manual social classes and those who could not be assigned a social class on the basis of their occupation were at increased risk for all three adverse outcomes studied. The babies of parents who were in manual occupations were twice as likely as those of parents in non-manual occupations to be small for gestational age and almost twice as likely to be low birthweight. CONCLUSIONS--Mother's social class is a risk factor for adverse pregnancy outcome independent of maternal age, parity, and adverse reproductive history, and also independent of father's social class. Information on both parents' occupations should be collected in maternity discharge systems.
PMCID: PMC1060759  PMID: 1757762
15.  Hyaline membrane disease, alkali, and intraventricular haemorrhage. 
Archives of Disease in Childhood  1976;51(10):755-762.
The relation between intraventricular haemorrhage (IVH) and hyaline membrane disease (HMD) was studied in singletons that came to necropsy at Hammersmith Hospital over the years 1966-73. The incidence of IVH in singleton live births was 3-22/1000 and of HMD 4-44/1000. Although the high figures were partily due to the large number of low birthweight infants born at this hospital, the incidence of IVH in babies weighing 1001-1500 g was three times as great as that reported in the 1658 British Perinatal Mortality Survey. Most IVH deaths were in babies with HMD, but the higher frequency of IVH was not associated with any prolongation of survival time of babies who died with HMD as compared with the 1958 survey. IVH was seen frequently at gestations of up to 36 weeks in babies with HMD but was rare above 30 weeks' gestation in babies without HMD. This indicated that factors associated with HMD must cause most cases of IVH seen at gestations above 30 weeks. Comparison of clinical details in infants with HMD who died with or without IVH (at gestations of 30-37 weeks) showed no significant differences between the groups other than a high incidence of fits and greater use of alkali therapy in the babies with IVH. During the 12 hours when most alkali therapy was given, babies dying with IVD received a mean total alkali dosage of 10-21 mmol/kg and those dying without IVH 6-34 mmol/kg (P less than 0-001).There was no difference in severity of hypoxia or of metabolic acidosis between the 2 groups. Babies who died with HMD and germinal layer haemorrhage (GLH) without IVH had received significantly more alkali than those who died with HMD alone, whereas survivors of severe respiratory distress syndrome had received lower alkali doses than other groups. It is suggested that the greatly increased death rate from IVH in babies with HMD indicates some alteration of management of HMD (since 1958) as a causative factor. Liberal use of hypertonic alkali solutions is the common factor which distinguishes babies dying with GLH and IVH from other groups of babies with HMD. Although the causal nature of this association remains unproved, it seems justifiable to lrge caution in alkali usage.
PMCID: PMC1546129  PMID: 1008580
16.  Teenage Pregnancy: A Socially Inflicted Health Hazard 
Early marriage and confinement are contributing factors to high maternal and perinatal mortality and morbidity.
To assess the magnitude of the problem of teenage pregnancy and its complications.
Materials and Methods:
A hospital-based cohort study was undertaken over 4 months among women admitted to a rural hospital in West Bengal. The study cohort comprised of teenage mothers between 15-19 years old and a control cohort of mothers between 20-24 years old. Data included demographic variables, available medical records, and complications viz. anemia, preterm delivery, and low birth weight. Anemia was defined as a hemoglobin level below 10 gm% during the last trimester of pregnancy, preterm delivery was defined as occurring within 37 weeks of gestation, and low birth weight was defined as babies weighing less than 2500 grams at birth.
Teenage pregnancy comprised 24.17% of total pregnancies occurring in the hospital during the study period. The study group had 58 subjects and the control group had 91 subjects. The prevalence of anemia was significantly higher (P<0.05) in the women in the teenage group (62.96%) than in the women in the control group (43.59%). However, severe anemia with a hemoglobin level below 8 gm% was only found in the control group. Preterm delivery occurred significantly more (P<0.001) in the study group (51.72%) than in the control group (25.88%). The incidence of low birth weight was significantly higher (P<0.0001) among the group of teenagers (65.52%) than among the women in the control group (26.37%). Not a single newborn was above 3 kg in the study group, while none were below 1.5 kg in the control group. The mean birth weight was 2.36 kg in the study group and 2.74 kg in the control group; the difference was strongly significant (P<0.001).
The study shows that anemia, preterm delivery, and low birth weight were more prevalent among teenagers than among women who were 20-24 years old. This indicates the need for enhancing family welfare measures to delay the age at first pregnancy, thereby reducing the multiple complications that may occur in the young mother and her newborn baby.
PMCID: PMC2800903  PMID: 20049301
Anemia; complications; low birth weight; preterm delivery; teen pregnancy
17.  Mortality risk in preterm and small-for-gestational-age infants in low-income and middle-income countries: a pooled country analysis 
Lancet  2013;382(9890):417-425.
Babies with low birthweight (<2500 g) are at increased risk of early mortality. However, low birthweight includes babies born preterm and with fetal growth restriction, and not all these infants have a birthweight less than 2500 g. We estimated the neonatal and infant mortality associated with these two characteristics in low-income and middle-income countries.
For this pooled analysis, we searched all available studies and identified 20 cohorts (providing data for 2 015 019 livebirths) from Asia, Africa, and Latin America that recorded data for birthweight, gestational age, and vital statistics through 28 days of life. Study dates ranged from 1982 through to 2010. We calculated relative risks (RR) and risk differences (RD) for mortality associated with preterm birth (<32 weeks, 32 weeks to <34 weeks, 34 weeks to <37 weeks), small-for-gestational-age (SGA; babies with birthweight in the lowest third percentile and between the third and tenth percentile of a US reference population), and preterm and SGA combinations.
Pooled overall RRs for preterm were 6·82 (95% CI 3·56–13·07) for neonatal mortality and 2·50 (1·48–4·22) for post-neonatal mortality. Pooled RRs for babies who were SGA (with birthweight in the lowest tenth percentile of the reference population) were 1·83 (95% CI 1·34–2·50) for neonatal mortality and 1·90 (1·32–2·73) for post-neonatal mortality. The neonatal mortality risk of babies who were both preterm and SGA was higher than that of babies with either characteristic alone (15·42; 9·11–26·12).
Many babies in low-income and middle-income countries are SGA. Preterm birth affects a smaller number of neonates than does SGA, but is associated with a higher mortality risk. The mortality risks associated with both characteristics extend beyond the neonatal period. Differentiation of the burden and risk of babies born preterm and SGA rather than with low birthweight could guide prevention and management strategies to speed progress towards Millennium Development Goal 4—the reduction of child mortality.
Bill & Melinda Gates Foundation.
PMCID: PMC3796350  PMID: 23746775
18.  Perinatal outcome and antenatal care in a black South African population. 
The Ulster Medical Journal  1993;62(1):37-43.
The relationship between perinatal outcome and antenatal care was investigated at King Edward VIII Hospital, Durban, by a case control retrospective study of pregnancy records in 165 perinatal deaths and 156 infants surviving the perinatal period. 82% of the mothers of live infants had booked for antenatal care compared with only 60% of those who experienced a perinatal death. Hospital booking was associated with a higher infant birthweight. For those who booked earlier there was no reduction in total perinatal mortality or the stillbirth:neonatal death ratio, and many of the mothers of highest risk failed to book. This suggests that the better perinatal outcome in booked mothers may have been secondary to the type of mother who chose to book, rather than the actual antenatal care. To help reduce perinatal mortality, methods must be employed which reach those mothers who are most likely to fail to book.
PMCID: PMC2449017  PMID: 8516973
19.  Intrauterine Growth Restriction: Effects of Physiological Fetal Growth Determinants on Diagnosis 
The growth of the fetus, which is strongly associated with the outcome of pregnancy, reflects interplay of several physiological and pathological factors. The assessment of fetal growth is based on comparison of birthweight (BW) or estimated fetal weight (EFW) to standards which define reference ranges at a spectrum of gestational ages. Most birthweight standards do not take into account effects of physiological determinants of fetal growth. Additionally, gestational age in many standards is based on the menstrual history and is often inaccurate. Fetal growth norms should be based on an early ultrasound estimate of gestational age. Customized standards, which have included only ultrasound-dated pregnancies, seem to be superior to population-based birthweight norms in predicting perinatal mortality and morbidity. Adjustment for individual variation in customized growth curves reduces false-positive diagnosis of IUGR and may lead to a very significant reduction in intervention for suspected IUGR. Customized growth potential identifies better the risk for adverse outcome than the currently used national standards, but customized charts may fail in detecting growth-restricted stillbirth. An individual's birthweight is the sum of physiological and pathological influences operating during pregnancy. Growth potential norms are a better discriminator of aberrations of fetal growth than population, ultrasound, and customized norms.
PMCID: PMC3705870  PMID: 23864862
20.  Perinatal outcomes for extremely preterm babies in relation to place of birth in England: the EPICure 2 study 
Expertise and resources may be important determinants of outcome for extremely preterm babies. We evaluated the effect of place of birth and perinatal transfer on survival and neonatal morbidity within a prospective cohort of births between 22 and 26 weeks of gestation in England during 2006.
We studied the whole population of 2460 births where the fetus was alive at the admission of the mother to hospital for delivery. Outcomes to discharge were compared between level 3 (most intensive) and level 2 maternity services, with and without transfers, and by activity level of level 3 neonatal unit; ORs were adjusted for gestation at birth and birthweight for gestation (adjusted ORs (aOR)).
Of this national birth cohort, 56% were born in maternity services with level 3 and 34% with level 2 neonatal units; 10% were born in a setting without ongoing intensive care facilities (level 1). When compared with level 2 settings, risk of death in level 3 services was reduced (aOR 0.73 (95% CI 0.59 to 0.90)), but the proportion surviving without neonatal morbidity was similar (aOR 1.27 (0.93 to 1.74)). Analysis by intended hospital of birth confirmed reduced mortality in level 3 services. Following antenatal transfer into a level 3 setting, there were fewer intrapartum or labour ward deaths, and overall mortality was higher for those remaining in level 2 services (aOR 1.44 (1.09 to 1.90)). Among level 3 services, those with higher activity had fewer deaths overall (aOR 0.68 (0.52 to 0.89)).
Despite national policy, only 56% of births between 22 and 26 weeks of gestation occurred in maternity services with a level 3 neonatal facility. Survival was significantly enhanced following birth in level 3 services, particularly those with high activity; this was not at the cost of increased neonatal morbidity.
PMCID: PMC3995269  PMID: 24604108
Neonatology; Epidemiology
21.  Preconceptional factors associated with very low birthweight delivery in East and West Berlin: a case control study 
BMC Public Health  2002;2:10.
Very low birthweight, i.e. a birthweight < 1500 g, is among the strongest determinants of infant mortality and childhood morbidity. To develop primary prevention approaches to VLBW birth and its sequelae, information is needed on the causes of preterm birth, their personal and social antecedents, and on conditions associated with very low birthweight. Despite the growing body of evidence linking sociodemographic variables with preterm delivery, little is known as to how this may be extrapolated to the risk of very low birthweight.
In 1992, two years after the German unification, we started to recruit two cohorts of very low birthweight infants and controls in East and West Berlin for a long-term neurodevelopmental study. The present analysis was undertaken to compare potential preconceptional risk factors for very low birthweight delivery in a case-control design including 166 mothers (82 East vs. 84 West Berlin) with very low birthweight delivery and 341 control mothers (166 East vs. 175 West).
Multivariate logistic regression analysis was used to assess the effects of various dichotomous parental covariates and their interaction with living in East or West Berlin. After backward variable selection, short maternal school education, maternal unemployment, single-room apartment, smoking, previous preterm delivery, and fetal loss emerged as significant main effect variables, together with living in West Berlin as positive effect modificator for single-mother status.
Very low birthweight has been differentially associated with obstetrical history and indicators of maternal socioeconomic status in East and West Berlin. The ranking of these risk factors is under the influence of the political framework.
PMCID: PMC117217  PMID: 12095425
Increasing paternal birthweight has been associated with increased risk of fathering a preterm infant, causing speculation that a fetus programmed to grow rapidly can trigger preterm labor.
Pregnancies occurring from 1974 to 1989 among women themselves born in the Danish Perinatal Study (1959–61) were identified through the Population Register; obstetrical records were abstracted. Paternal birthweight was obtained by linking Personal Identification Numbers of the fathers to archived midwifery records.
Paternal birthweight was not associated with preterm infants overall. However, there was a significant interaction between paternal and maternal birthweights (p=0.003). When the mother weighed <3 kg at birth, increasing paternal birthweight was associated with increased occurrence of preterm birth (p for trend=0.02); paternal birthweight was unassociated with preterm birth for mothers weighing ≥3 kg at birth (p=0.34).
When the mother was born small, increasing paternal birthweight was associated with increased risk of preterm birth, suggesting that a fetus growing faster than its mother can accommodate might trigger preterm birth.
PMCID: PMC2213511  PMID: 18166307
Birthweight; genetics; paternal effects
23.  Aluminium sulphate in water in north Cornwall and outcome of pregnancy. 
BMJ : British Medical Journal  1991;302(6786):1175-1177.
OBJECTIVE--To determine whether the excess aluminum sulphate accidentally added to the local water supply in north Cornwall in July 1988 had an adverse effect on the outcome of pregnancies. DESIGN--Outcomes of all singleton pregnancies in the affected area at the time of the incident (n = 92) were compared with those in two control groups: pregnancies in this area completed before the incident (n = 68) and pregnancies in a neighbouring area (n = 193). SUBJECTS--Mothers in the three groups, among whom there were 13 miscarriages, five terminations of pregnancy, and 336 live births. MAIN OUTCOME MEASURES--Fetal and perinatal loss, birth weight, gestation, obstetric complications, neonatal condition, and congenital defects. RESULTS--Among 88 pregnancies in women exposed to excess aluminum sulphate there was no excess of perinatal deaths (n = 0), low birthweight (n = 3), preterm delivery (n = 4), or severe congenital malformations (n = 0). There was, however, an increased rate of talipes in exposed fetuses (four cases, one control; p = 0.01). CONCLUSIONS--Because of small numbers it is not possible to say that high doses of aluminum sulphate are safe in pregnancy, but there is no evidence from this study of major problems apparent at birth.
PMCID: PMC1669867  PMID: 2043811
24.  Thinness at birth in a northern industrial town. 
OBJECTIVE--To determine whether babies in an area of Britain with unusually high perinatal mortality have different patterns of fetal growth to those born elsewhere in the country. DESIGN--Measurement of body size in newborn babies. SETTING--Burnley (perinatal mortality in 1988 15.9/1000 total births) and Salisbury (perinatal mortality 10.8/1000 total births), England. SUBJECTS--Subjects comprised 1544 babies born in Burnley, Pendle, and Rossendale Health District, and 1025 babies born in Salisbury Health District. MAIN OUTCOME MEASURES--Birthweight, length, head, arm and abdominal circumferences, and placental weight were determined. RESULTS--Compared with babies born in Salisbury, Burnley babies had lower mean birthweight (difference 116 g, 95% confidence interval (CI) 77,154), smaller head circumferences (difference 0.3 cm, 95% CI 0.2, 0.4), and were thinner as measured by arm circumference (difference 0.3 cm, 95% CI 0.3, 0.4), abdominal circumference (difference 0.5 cm, 95% CI 0.4, 0.6) and ponderal index (difference 0.8 kg/m3, 95% CI 0.6, 1.0). The ratio of placental weight to birthweight was higher in Burnley (difference 0.6%, 95% CI 0.4, 0.9). These differences were found in boys and girls and did not depend on differences in duration of gestation or on the different ethnic mix of the two districts. Mothers in Burnley were younger, shorter in stature, had had more children, were of lower social class, and more of them smoked during pregnancy than mothers in Salisbury. These differences did not explain the greater thinness of their babies. CONCLUSIONS--Babies born in Burnley, an area with high perinatal mortality, are thin. The reason is unknown. Poor maternal nutrition is suspected because Burnley babies have a higher ratio of placental weight to birthweight. The greater thinness at birth of Burnley babies could have long term consequences, including higher rates of cardiovascular disease.
PMCID: PMC1059788  PMID: 8228757
25.  Intrauterine growth pattern and birthweight discordance in twin pregnancies: a retrospective study 
Twins, compared to singletons, have an increased risk of perinatal mortality and morbidity, due mainly to a higher prevalence of preterm birth and low birthweight. Intrauterine growth restriction (IUGR) is also common and can affect one or both fetuses. In some cases, however, one twin is much smaller than the other (growth discordance). Usually, high birthweight discordance is associated with increased perinatal morbidity. The aim of this study is to describe the epidemiological features of a population of twins at birth, with particular reference to the interpretation and clinical effects of birthweight discordance.
We evaluated retrospectively the clinical features of 70 infants born from twin pregnancies and assessed birthweight discordance in 31 pregnancies where both twins were followed at our institution. Discordance was treated both as a continuous and a categorical variable, using a cutoff of 18%. Possible relationships between birthweight discordance and other variables, such as maternal age, gestational age, birthweight percentile, number of SGA newborns in the pair, Hematocrit (Ht) discordance and neonatal anemia, prevalence of malformations, neonatal morbidity and death, were analyzed.
In our cohort birthweight percentile decreased slightly with increasing gestational age. Birthweight discordance, on the contrary, increased slightly with the increase of gestational age.
A high discordance is associated to the presence of one SGA twin, with the other AGA or LGA. In our population, all 6 pregnancies in which discordance exceeded 18% belonged to this category (one SGA twin).
Ht discordance at birth is associated to the presence of neonatal anemia in a twin, but it is not significantly related to weight discordance.
Finally, in our case history, weight discordance is not associated in any way with the prevalence of malformations, morbidity and mortality.
Birthweight discordance is an important indicator of complications that act asymmetrically on the two fetuses, affecting intrauterine growth in one of them, and usually determining the birth of a SGA infant.
Our case history shows a significant statistical association between pair discordance and IUGR in one of the twins, but we could not demonstrate any relationship between discordance and the prevalence of malformations, morbidity and mortality.
PMCID: PMC4018970  PMID: 24887062
Twins; Birthweight discordance; SGA; Weight percentile; Neonatal anemia

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