Higher Risk Of Neonatal Mortality Research Articles

Maternal age at birth and neonatal mortality: Associations from 67 low-income and middle-income countries.

Both young and advanced maternal age have been associated with higher risks of neonatal mortality, but most studies are from high-income countries and the evidence from low- and middle-income countries (LMICs) is scarce. To investigate the association between maternal age at delivery and neonatal mortality in LMICs. This is a cross-sectional study using data from 159 Demographic and Health Surveys in 67 LMICs between 2000 and 2018. Maternal age at the time of the birth was the exposure variable, and neonatal mortality was the outcome. Multivariable logistic regression model taking into consideration complex survey design was performed with adjustments for maternal education level, paternal education level, rural/urban residence, country, and survey year. Subgroup analyses were performed by time of death, sex, the country's World Bank income classification, the World Health Organization region, and survey year. A total of 1395746 mother-neonate pairs were included. Overall, compared with neonates born to mothers aged 25-29years, those born to younger mothers aged 20-24, 16-19 and 12-15years were at an increased risk of mortality (adjusted odds ratio [OR] 1.24, 95% confidence interval [CI] 1.17, 1.30; OR 1.81, 95% CI 1.71, 1.93; OR 2.29, 95% CI 1.96, 2.67, respectively). Neonates born to mothers aged 30-34, 35-39, 40-44, and ≥45years were also at an increased risk of mortality (OR 1.09, 95% CI 1.03, 1.15; OR 1.30, 95% CI 1.21, 1.39; OR 1.50, 95% CI 1.38, 1.64; OR 1.84, 95% CI 1.54, 2.20, respectively). The results were consistent across most subgroup analyses. Neonates born to younger (<25years) and older mothers (≥30years) are at increased risk of neonatal death in LMICs.

Neurally-Adjusted Ventilatory Assist Can Facilitate Extubation in Neonates With Congenital Diaphragmatic Hernia.

Congenital diaphragmatic hernia is associated with a high risk of neonatal mortality and long-term morbidity due to lung hypoplasia, pulmonary hypertension, and prolonged exposure to positive-pressure ventilation. Ventilator-associated lung injury may be reduced by using approaches that facilitate the transition from invasive ventilation to noninvasive ventilation (NIV), such as with neurally-adjusted ventilatory assist (NAVA). We reported our use of NAVA in neonatal patients with congenital diaphragmatic hernia during the transition from invasive ventilation to NIV. A retrospective analysis of neonatal subjects with congenital diaphragmatic hernia admitted to a tertiary care children's hospital between December 2015 and May 2018 was conducted. Subject data and factors that affected the use of NAVA were analyzed. Ten neonatal subjects with congenital diaphragmatic hernia were placed on NAVA, and 6 were successfully transitioned, after surgery, from pressure control synchronized intermittent mandatory ventilation to invasive ventilation with NAVA and then to NIV with NAVA without the need for re-intubation. The transition from pressure control synchronized intermittent mandatory ventilation to invasive ventilation with NAVA resulted in a decrease in peak inspiratory pressure, mean airway pressure, and [Formula: see text]. Barriers to the use of NAVA included symptomatic pleural effusion or chylothorax and pulmonary sequestration. Both invasive ventilation with NAVA and NIV with NAVA were used successfully in subjects with congenital diaphragmatic hernia during the transition from invasive ventilation to NIV. The transition to NAVA was associated with a decrease in peak inspiratory pressure, mean airway pressure, and the need for supplemental oxygen. A prospective trial is needed to determine the short- and long-term impacts of this mode of ventilation in neonates with congenital diaphragmatic hernia.

A model of puppy growth during the first three weeks.

Neonatal mortality in puppies is highly variable, with large scale surveys still reporting average values around 10% –15%. Weight measurement is the simplest way to monitor the development of the puppies, and a weight loss during the first 48 hr has been recognized as one of the factors that puts puppies at a higher risk of neonatal mortality. However, little is known about what constitutes optimum growth up to 3 weeks. In this study, a mathematical formula with the form P = P 0 exp (0.13084 x ‐ 0.001616 x2), where P is weight on Day x and P 0 is weight on Day 0, obtained by multiple linear regression, is presented and validated with data from 345 puppies belonging to 60 litters of 19 different breeds, from toy to giant size, showing that it appropriately describes maximum puppy growth rate during the neonatal period for all breeds. This formula is in agreement with previous studies and generic recommendations that can be found in the literature on puppy growth from birth to 21 days regarding relative daily weight gain. It can be easily introduced in a spreadsheet or used to build growth charts that can help the breeder or the veterinarian in monitoring and evaluating puppy growth during the neonatal period. Although deviations from the maximum growth rate can now be quantified, there is still a need to determine the limits beyond which supplementary feeding is advised/required.

Meconium aspiration syndrome: incidence, associated risk factors and outcome-evidence from a multicentric study in low-resource settings in Nepal.

The aim of this study was to identify the incidence, risk factors and outcome associated with meconium aspiration syndrome (MAS). An observational study was conducted in 12 public hospitals in Nepal from 1 July 2017 to 29 August 2018. All babies born within the study period were included in the study. Babies who were diagnosed as MAS were designated as outcome. Data were analysed with bivariate analysis followed by multiple regression analysis. The overall incidence of MAS was 2.0 per 1000 livebirths. Babies born at post-term gestation (adjusted odds ratio (AOR) = 2.41; 95% confidence interval (CI): 1.05-5.55), nulliparity (AOR = 2.26; 95% CI: 1.20-4.28), instrumental delivery (AOR = 4.79; 95% CI: 2.52-9.10) and caesarean delivery (AOR = 3.67; 95% CI: 2.29-5.89) were significantly associated with MAS. Babies with MAS had a 10-fold risk for pre-discharge mortality (odds ratio = 9.87; 95% CI: 5.81-16.76). The findings in this study are consistent with that reported in other studies. MAS has a high risk of neonatal mortality. Thus, monitoring during pregnancy and labour is necessary for early identification of high-risk conditions associated with MAS. Strengthening of newborn care services is essential to curtail mortality.

Birth weight as a risk factor for neonatal mortality: Breed-specific approach to identify at-risk puppies

In numerous species, low birth weight is a risk factor for neonatal mortality. In the canine species, definition of a low birth weight is complex due to the huge interbreed variability in size. To identify puppies at higher risk of neonatal death, data from 6,694 puppies were analysed. The data were collected from 75 French breeding kennels, examining 27 breeds and totaling 1,202 litters of puppies. Generalised linear mixed models allowed to identify birth weight, birth weight heterogeneity within the litter, and size of the breeding kennel as significant risk factors for neonatal mortality. Receiver Operating Characteristics (ROC) and classification and regression tree (CART) analyses were combined to define breed specific thresholds for birth weight allowing the identification of puppies at higher risk of neonatal mortality. Due to differences in birth weights between breeds, including when belonging to the same breed size, analyses were conducted at the breed level. First, ROC analysis thresholds were successfully established for 12 breeds (area under the ROC ≥ 0.70; sensitivity ≥ 75%; specificity: 45–68%) and they ranged from 162 g in the Maltese to 480 g in the Bernese Mountain dog. Secondly, CART analysis thresholds from 22 breeds ranged from 105 g in the Maltese and 436 g in the Boxer. Puppies were grouped into three categories according to birth weight: low, moderate and high risk of neonatal mortality (higher than the ROC threshold, between ROC and CART thresholds, and lower than the CART threshold respectively). In the current study, 44% of the puppies were classified as at moderate risk and 5.3% for a high risk of neonatal mortality. Thresholds defined by CART analysis (and not ROC analysis) were used to define low birth weight puppies and were sometimes quite different between breeds with similar birth weight distributions suggesting a variable relationship between birth weight reduction and neonatal death. These results allow the identification of puppies at an increased risk of neonatal death, thus requiring specific nursing to improve their chances of survival. With these high risk puppies identified, both animal welfare and kennel productivity is predicted to improve.

Global incidence of bronchopulmonary dysplasia among extremely preterm infants: a systematic literature review

Background Infants born extremely preterm (<28 weeks gestational age (GA)) face a high risk of neonatal mortality. Bronchopulmonary dysplasia (BPD) is the most common morbidity of prematurity. Objective To evaluate the global incidence of BPD among infants born extremely preterm. Design A systematic review of the literature was conducted in Embase and MEDLINE (via PubMed) using a prespecified search strategy for BPD and prematurity. Observational studies published in English between 16 May 2006 and 16 October 2017 reporting on the occurrence of BPD in infants born <28 weeks GA were included. Results Literature searches yielded 103 eligible studies encompassing 37 publications from Europe, 38 publications from North America, two publications from Europe and North America, 19 publications from Asia, one publication from Asia and North America, six publications from Oceania, and zero publications from Africa or South America. The reported global incidence range of BPD was 10–89% (10–73% in Europe, 18–89% in North America, 18–82% in Asia, and 30–62% in Oceania). When only population-based observational studies that defined BPD as requiring supplemental oxygen at 36 weeks postmenstrual age were included, the global incidence range of BPD was 17–75%. The wide range of incidences reflected interstudy differences in GA (which was inversely related to BPD incidence), birthweight, and survival rates across populations and institutions. Conclusions BPD is a common health morbidity occurring with extremely preterm birth. Further study of factors that impact incidence, aside from low GA, may help to elucidate modifiable risks.

NEONATAL AND FETAL EFFECTS OF ANTITHYROID PEROXIDASE POSITIVITY IN HYPOTHYROIDISM IN PREGNANCY - A HOSPITAL-BASED PROSPECTIVE ANALYTICAL STUDY

Objectives: The objectives of this study were to evaluate the fetal and neonatal outcomes for pregnant women with autoimmune hypothyroidism and to compare them to hypothyroid and euthyroid women. Methods: A total of 309 women were included in the study. 159 hypothyroid women were categorized as “Cases” and 150 euthyroid women were “Controls.” Serum thyroid-stimulating hormone (TSH) was done for all women, and in hypothyroid women, antithyroid peroxidase (TPO) was also done for the mothers. Cases were subdivided on the basis of anti-TPO positivity. Fetal and neonatal complications were noted in all three groups along with basic parameters such as baby weight and Apgar scores. Meconium aspiration, neonatal intensive care unit (NICU) admission, jaundice, intrauterine growth retardation, intrauterine death (IUD), low or very low birth weight, congenital anomalies, hypothyroidism in the newborn, and neonatal death were the parameters noted. Testing of the babies was done with serum TSH on day of life 3 and serum bilirubin whenever clinically jaundice was suspected. The study period was 2 years. Results: Hypothyroidism is significantly associated with an increased risk of IUD (p=0.038), NICU admissions in babies (p=0.004), neonatal jaundice (p=0.027), low or very low birth weight babies (p=0.0003), congenital anomalies in the babies (p=0.026), and neonatal deaths (p=0.007). Anti-TPO positivity is significantly associated with increased risk of IUD (p=0.044) and hypothyroidism in the newborn of hypothyroid mothers (p=0.045). Conclusions: Anti-TPO positivity and hypothyroidism are both significantly associated with certain fetal complications such as IUD, neonatal jaundice, increased NICU admissions, and hypothyroidism in the newborn. Mothers with hypothyroidism who are TPO positive have a higher risk of neonatal mortality and morbidity, although small. Hence, screening should be done in all hypothyroid women in pregnancy and their babies. Universal screening with serum TSH is recommended in pregnancy and in the newborn on day 3 of life.

The Course of Parturition Affects Piglet Condition at Birth and Survival and Growth through the Nursery Phase.

Simple SummaryIn this study, data were collected on the condition in which piglets were born, and this was related to their position in the birth order, and to the progress of parturition. The objective of the study was to find out if these observations were related to performance in early life, up to 10 weeks. It appeared that the later the piglets were born in a litter, the higher the risk of being stillborn, and this was aggravated in sows that took a relatively long time to give birth to their litter. In the first few piglets in a litter, risk of stillbirth was only 2%, whereas this increased to 17% in piglets born 13th in the litter or later. Similarly, birth order affected the condition of the liveborn piglets, with blood values such as pH being evident of suboptimal oxygenation in piglets born later. These blood values were predictive of neonatal behaviour such as colostrum intake, but also for neonatal survival and growth during suckling and even to 10 weeks of life. These data are the first in piglets to emphasise the impact of condition at birth on survival and growth until the end of the nursery phase.The aim of this study was to relate the course of parturition to the condition of piglets at birth, based on umbilical cord blood acid-base values, and relate the condition at birth to neonatal survival and performance up to 10 weeks of life. Data were collected from 37 spontaneous unassisted parturitions, and neonatal performance was based on observations of 516 piglets. Stillbirth rate increased from 2% in the first piglets, to 17% in piglets born 13th in the litter or later. This was aggravated in sows with longer than average stage II of parturition. Umbilical cord blood values also reflected the effect of birth order, with pH decreasing and lactate increasing in the course of parturition. Interestingly, sows that had a long expulsion stage of parturition also took longer to give birth to the first four piglets (r = 0.74), suggesting that sows with complicated parturition were already experiencing problems at the start of expulsion of piglets. Piglets with signs of asphyxia, based on umbilical blood lactate higher than 4.46 mmol/L, were slower to start suckling, had a higher risk of neonatal mortality, and had a slower growth rate over the first 10 weeks of life.

Indigenous Infant Mortality by Age and Season of Birth, 1800-1899: Did Season of Birth Affect Children's Chances for Survival?

This paper focuses on the influence of season of birth on infant mortality among the Sami and non-Sami populations in northern Sweden during the nineteenth century. The source material is a set of data files from the Demographic Data Base at Umeå University, making it possible to combine age at death (in days), month of death, and month of birth over the course of the entire century. Cox regression models reveal that for the first week of life, season of birth had no influence on the risk of mortality. For the Sami, the results showed that being born during winter was related to a higher risk of neonatal mortality, and being born during summer was related to a higher risk of mortality after six months of age. Furthermore, for the Sami, the neonatal mortality showed a U-shaped pattern with a minimum in June–August, whereas the corresponding pattern among the non-Sami was flatter. The findings shed light on vulnerability in two populations sharing the same environment, but diverging in terms of social, economic, and cultural factors.

Altered Right Ventricular Mechanical Properties Are Afterload Dependent in a Rodent Model of Bronchopulmonary Dysplasia.

Infants born premature are at increased risk for development of bronchopulmonary dysplasia (BPD), pulmonary hypertension (PH), and ultimately right ventricular (RV) dysfunction, which together carry a high risk of neonatal mortality. However, the role alveolar simplification and abnormal pulmonary microvascular development in BPD affects RV contractile properties is unknown. We used a rat model of BPD to examine the effect of hyperoxia-induced PH on RV contractile properties. We measured in vivo RV pressure as well as passive force, maximum Ca2+ activated force, calcium sensitivity of force (pCa50) and rate of force redevelopment (ktr) in RV skinned trabeculae isolated from hearts of 21-and 35-day old rats pre-exposed to 21% oxygen (normoxia) or 85% oxygen (hyperoxia) for 14 days after birth. Systolic and diastolic RV pressure were significantly higher at day 21 in hyperoxia exposed rats compared to normoxia control rats, but normalized by 35 days of age. Passive force, maximum Ca2+ activated force, and calcium sensitivity of force were elevated and cross-bridge cycling kinetics depressed in 21-day old hyperoxic trabeculae, whereas no differences between normoxic and hyperoxic trabeculae were seen at 35 days. Myofibrillar protein analysis revealed that 21-day old hyperoxic trabeculae had increased levels of beta-myosin heavy chain (β-MHC), atrial myosin light chain 1 (aMLC1; often referred to as essential light chain), and slow skeletal troponin I (ssTnI) compared to age matched normoxic trabeculae. On the other hand, 35-day old normoxic and hyperoxic trabeculae expressed similar level of α- and β-MHC, ventricular MLC1 and predominantly cTnI. These results suggest that neonatal exposure to hyperoxia increases RV afterload and affect both the steady state and dynamic contractile properties of the RV, likely as a result of hyperoxia-induced expression of β-MHC, delayed transition of slow skeletal TnI to cardiac TnI, and expression of atrial MLC1. These hyperoxia-induced changes in contractile properties are reversible and accompany the resolution of PH with further developmental age, underscoring the importance of reducing RV afterload to allow for normalization of RV function in both animal models and humans with BPD.

Monitoring of the newborn dog and prediction of neonatal mortality

Despite the high neonatal mortality rate in puppies, pertinent criteria for health evaluation of the newborns are not defined. This study was thus designed to measure and to characterize factors of variation of six health parameters in dog neonates, and to evaluate their value as predictors of neonatal mortality. A total of 347 purebred puppies under identical conditions of housing and management were examined within the first 8h after birth and then at Day 1. The first health evaluation included Apgar score, weight, blood glucose, lactate and β-hydroxybutyrate concentration, rectal temperature and urine specific gravity (SG). The second evaluation at Day 1 included the same parameters, excluding Apgar score and weight. The mortality rate over the first 24h and over 21days of age was recorded. The early predictors of neonatal mortality in the dog were determined with generalized linear mixed models and receiver operating characteristic curves analyses. An Apgar score at or below 6 evaluated within the first 8h after birth was found associated with a higher risk of death during the first 24h. A reduced glucose concentration (≤92mg/dl) at Day 1 was found to be associated with higher mortality between 1 and 21days of age. Low-birth-weight puppies were characterized by both low viability (low Apgar score) and low blood glucose concentration, and thus were found indirectly at higher risk of neonatal mortality. This study promotes two low cost easy-to-use tests for health evaluation in puppies, i.e. Apgar scoring and blood glucose assay. Further investigation is necessary to establish if the strong relationship between blood glucose and neonatal survival reflects high energy requirements or other benefits from colostrum intake.

Effect of Birth Interval on Neonatal and Post Neonatal Mortality in Bangladesh

This study investigates the relationship between previous birth interval and infant mortality using the data extracted from the Bangladesh Demographic and Health Survey (BDHS), 2011. For the purpose of regression analysis, the Cox proportional hazard model has been used. Results demonstrate significant effects of previous birth interval on neonatal mortality, but not on post neonatal mortality. If the previous birth interval is less than two years or greater than three years, the index child experiences high risk of neonatal mortality.&#x0D; Dhaka Univ. J. Sci. 65(1): 35-39, 2017 (January)

Antenatal care visits during pregnancy and their effect on maternal and fetal outcomes in pre-eclamptic patients.

The frequency of antenatal care visits during pregnancy was examined to determine their effect on maternal and fetal outcomes in patients with pre-eclampsia. This study included 150 pregnant women with pre-eclampsia who attended the Outpatient Clinic of the Obstetrics and Gynecology Department, Ismailia General Hospital. The women were interviewed and their antenatal care visits recorded. Blood pressure control, cardiotocography, ultrasonographic and Doppler evaluations and the administration of methyldopa were recorded. We calculated the distribution of women who attended an adequate versus an inadequate number of antenatal care visits, examined the characteristics of the groups using significance tests, computed the risk of poor maternal and fetal outcomes and created regression analysis models. We also calculated the incidence rate of poor maternal and fetal outcomes, odds ratios and 95% confidence intervals. Women who attended an inadequate number of antenatal care visits had a significantly higher risk of post-partum hemorrhage, eclampsia, and intensive care unit admission compared with women who attended an adequate number of visits. Women who attended an inadequate number of visits had a 12-fold risk of a poor maternal outcome, a 53-fold risk of a poor fetal outcome and a significantly higher risk of neonatal mortality in comparison to women who attended an adequate number of antenatal visits. The frequency of antenatal care visits during pregnancy has a significant effect on maternal and fetal outcomes in patients with pre-eclampsia.

Prophylactic oral betamimetics for reducing preterm birth in women with a twin pregnancy.

Twin pregnancies are associated with a high risk of neonatal mortality and morbidity due to an increased rate of preterm birth. Betamimetics can decrease contraction frequency or delay preterm birth in singleton pregnancies by 24 to 48 hours. The efficacy of oral betamimetics in women with a twin pregnancy is unproven. To assess the effectiveness of prophylactic oral betamimetics for the prevention of preterm labour and birth for women with twin pregnancies. We searched the Cochrane Pregnancy and Childbirth Group Trials Register (21 September 2015), MEDLINE (January 1966 to 31 July 2015), EMBASE (January 1985 to 31 July 2015) and reference lists of retrieved studies. Randomised controlled trials in twin pregnancies comparing oral betamimetics with placebo or any intervention with the specific aim of preventing preterm birth. Quasi-randomised controlled trials, cluster-randomised trials and cross-over trials were not eligible for inclusion. Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Two authors assessed the quality of the evidence using the GRADE approach. Overall, the quality of evidence is low for the primary outcomes. All of the included trials had small numbers of participants and few events. Preterm birth, the most important primary outcome, had wide confidence intervals crossing the line of no effect.Six trials (374 twin pregnancies) were included, but only five trials (344 twin pregnancies) contributed data. All trials compared oral betamimetics with placebo.Betamimetics reduced the incidence of preterm labour (two trials, 194 twin pregnancies, risk ratio (RR) 0.37; 95% confidence interval (CI) 0.17 to 0.78; low quality evidence). However, betamimetics did not reduce prelabour rupture of membranes (one trial, 144 twin pregnancies, RR 1.42; 95% CI 0.42 to 4.82; low quality evidence), preterm birth less than 37 weeks' gestation (four trials, 276 twin pregnancies, RR 0.85; 95% CI 0.65 to 1.10; low quality evidence), or less than 34 weeks' gestation (one trial, 144 twin pregnancies, RR 0.47; 95% CI 0.15 to 1.50; low quality evidence). Mean neonatal birthweight in the betamimetic group was significantly higher than in the placebo group (three trials, 478 neonates, mean difference 111.22 g; 95% CI 22.21 to 200.24). Nevertheless, there was no evidence of an effect of betamimetics in reduction of low birthweight (two trials, 366 neonates, average RR 1.19; 95% CI 0.77 to 1.85, random-effects), or small-for-gestational age neonates (two trials, 178 neonates, average RR 0.90; 95% CI 0.41 to 1.99, random-effects). Two trials showed that betamimetics significantly reduced the incidence of respiratory distress syndrome (388 neonates, RR 0.30; 95% CI 0.12 to 0.77), but the difference was not significant when the analysis was adjusted to account for the non-independence of twins (194 twins, RR 0.35; 95% CI 0.11 to 1.16). Three trials showed no evidence of an effect of betamimetics in reducing neonatal mortality, either with the unadjusted analysis, assuming twins are completely independent of each other (452 neonates, average RR 0.90; 95% CI 0.15 to 5.37, random-effects), or in the adjusted analysis, assuming non-independence of twins (226 twins, average RR 0.74; 95% CI 0.23 to 2.38, random-effects). A maternal death was reported in one trial without a significant difference between the groups (144 women, RR 2.84; 95% CI 0.12 to 68.57). There is insufficient evidence to support or refute the use of prophylactic oral betamimetics for preventing preterm birth in women with a twin pregnancy.

Long-term burden of care and radiation exposure in survivors of esophageal atresia

BackgroundPatients with esophageal atresia with or without tracheoesophageal fistula (EA/TEF) historically have had a high risk of neonatal mortality but the majority of patients are now expected to live into adulthood. However, the long-term burden of care among recent EA/TEF survivors has not been documented. MethodsA single-institution retrospective review of newborns with EA/TEF treated from 2001-2005 was conducted, including initial and total hospitalization length of stay, and number of clinic visits and procedures requiring general anesthesia in the first three years of life. Exposure to and number of radiological studies involving ionizing radiation (IR) were recorded. ResultsSeventy-one of 78 (91%) patients survived to discharge and 69 were included for analysis. Mean length of initial hospital stay was 51.3 (range 9-390) days. By age 3 years, patients required 4.5 (mean, range 1-23) procedures performed under general anesthesia, attended 13.5 (mean, range 3-40) outpatient visits and were exposed to 17.4 mSv (mean, range 3.0-59.9) of IR from 40 (mean, range 5-165) radiological studies. ConclusionPatients with EA/TEF need complex and frequent hospital-based care from infancy to early childhood. Opportunities to critically review clinical services and imaging needs should be explored to improve the experience of patients and their families.

A systematic review of risk factors for neonatal mortality in adolescent mother's in Sub Saharan Africa.

BackgroundWorldwide, approximately 14 million mothers aged 15 – 19 years give birth annually. The number of teenage births in Sub Saharan Africa (SSA) is particularly high with an estimated 50% of mothers under the age of 20. Adolescent mothers have a significantly higher risk of neonatal mortality in comparison to adults. The objective of this review was to compare perinatal/neonatal mortality in Sub Saharan Africa and it’s associated risk factors between adolescents and adults.ResultsWe systematically searched six databases to determine risk factors for perinatal/neonatal mortality, and pregnancy outcomes, between adolescent and adults in SSA. Article’s quality was assessed and synthesized as a narrative. Being single and having a single parent household is more prevalent amongst adolescents than adults. Nearly all the adolescent mothers (97%) were raised in single parent households. These single life factors could be interconnected and catalyze other risky behaviors. Accordingly, having co-morbidities such as Sexually Transmitted Infections, or not going to school was more prevalent in younger mothers.ConclusionsInter-generational support for single mothers in SSA communities appears essential in preventing both early pregnancies and ensuring healthy outcomes when they occur during adolescence. Future studies should test related hypothesis and seek to unpack the processes that underpin the relationships between being single and other risk indicators for neonatal mortality in young mothers. Current policy initiatives should account for the context of single African women’s lives, low opportunity, status and little access to supportive relationships, or practical help.Electronic supplementary materialThe online version of this article (doi:10.1186/1756-0500-7-750) contains supplementary material, which is available to authorized users.

Fetal Growth Restriction Is Worse than Extreme Prematurity for the Developing Lung

Background: Perinatal lung growth is highly vulnerable to inflammation and intrauterine growth restriction (IUGR), two major risk factors for chronic lung disease (CLD) in preterm neonates. However, the balance between extremely low gestational age (ELGA) and IUGR in very preterm infants as risk factors for CLD and co-morbidities remains poorly explored. Objectives: This single-center study aims to compare neonatal morbidity (including CLD) and mortality among ELGA infants with normal birth weight (ELGA-AGA), very preterm infants with IUGR <3rd percentile (VLGA-IUGR) and very preterm infants with a birth weight appropriate for gestational age (VLGA-AGA), matched with VLGA-IUGR infants. Methods: Selected characteristics of the perinatal and neonatal periods were recorded and retrospectively compared among the three groups. Infants with major congenital anomalies were excluded. The diagnosis of CLD was based on whether the infant was receiving supplemental oxygen and/or non-invasive ventilation at a postmenstrual age of 36 weeks. Results: We found that, despite a median difference of 3 weeks in gestational age at birth between VLGA-IUGR and ELGA-AGA infants, neonatal mortality was 35% higher in neonates who had experienced fetal growth restriction, and that VLGA- IUGR was five times more predictive of CLD than was ELGA-AGA. These differences persisted after adjustment for confounding factors such as antenatal steroids, gender and respiratory distress syndrome. Conclusions: This study reports that VLGA-IUGR infants are at higher risk of neonatal mortality and CLD than both ELGA-AGA and VLGA-AGA infants.

Trends in the incidence and mortality of multiple births by socioeconomic deprivation and maternal age in England: population-based cohort study

ObjectiveTo investigate temporal trends in multiple birth rates and associated stillbirth and neonatal mortality by socioeconomic deprivation and maternal age in England.DesignPopulation cohort study.SettingEngland.ParticipantsAll live births and stillbirths (1 January...

Where does distance matter? Distance to the closest maternity unit and risk of foetal and neonatal mortality in France

Background: The number of maternity units has declined in France, raising concerns about the possible impact of increasing travel distances on perinatal health outcomes. We investigated impact of distance to closest maternity unit on perinatal mortality. Methods: Data from the French National Vital Statistics Registry were used to construct foetal and neonatal mortality rates over 2001–08 by distance from mother’s municipality of residence and the closest municipality with a maternity unit. Data from French neonatal mortality certificates were used to compute neonatal death rates after out-of-hospital birth. Relative risks by distance were estimated, adjusting for individual and municipal-level characteristics. Results: Seven percent of births occurred to women residing at ≥30 km from a maternity unit and 1% at ≥45 km. Foetal and neonatal mortality rates were highest for women living at <5 km from a maternity unit. For foetal mortality, rates increased at ≥45 km compared with 5–45 km. In adjusted models, long distance to a maternity unit had no impact on overall mortality but women living closer to a maternity unit had a higher risk of neonatal mortality. Neonatal deaths associated with out-of-hospital birth were rare but more frequent at longer distances. At the municipal-level, higher percentages of unemployment and foreign-born residents were associated with increased mortality. Conclusion: Overall mortality was not associated with living far from a maternity unit. Mortality was elevated in municipalities with social risk factors and located closest to a maternity unit, reflecting the location of maternity units in deprived areas with risk factors for poor outcome.

Commentary: Foetal growth, preterm birth and childhood undernutrition

The application of the World Health Organization (WHO) Child Growth Standards released in 2006 showed that in many lowand middle-income countries (LMICs), a child’s length is already compromised at birth. In this issue of the IJE, Christian and colleagues make an important contribution to understanding the extent to which foetal growth restriction contributes to childhood stunting and other indicators of nutritional status. The consortium of researchers, pooling data from 19 birth cohorts from LMICs, show that childhood undernutrition has its origins in the foetal period. Relative to children born adequate size-for-gestational age (AGA) and at term, the odds ratios of childhood (12–60 months) stunting associated with AGA and preterm; smallfor-gestational age (SGA) and term; and SGA and preterm; are 1.93, 2.43 and 4.51, respectively. A similar magnitude of risk is observed for wasting and underweight. Importantly, despite the large variation in the prevalence of both SGA and preterm birth, the risk of undernutrition associated with being born too small or too soon is comparable across populations and regions, reflecting common underlying causes of either foetal growth restriction or preterm birth. The results indicate a stronger association between SGA and stunting than between preterm and stunting. In contrast, preterm birth – which affects a smaller number of neonates – is associated with a higher risk of neonatal mortality, with relative risk ranging from 6 to 9 vs. SGA alone, which was consistently associated with a 3-fold increased risk. In 1998 we reported a first attempt to estimate the burden of intrauterine growth restriction in LMICs. Knowledge has evolved and today we are better able to estimate the large number of babies born each year too small or too soon. In other respects, however, past challenges remain. An important one is accurately assessing gestational age in LMICs in the context of antenatal care programmes. Furthermore, the definition of what constitutes ‘normal’ foetal growth continues to be hotly debated. At present, there is no classification system that incorporates both the clinical heterogeneity and the multi-causality of foetal growth disturbances reflecting the lower and upper ends of the distribution, including describing the different phenotypes associated with disturbed foetal growth. Ideally, a unified classification should be developed that is consistent with the definitions and terminology commonly used in postnatal life so that there is a harmonized approach to classifying disturbances in human growth from early pregnancy to childhood. An important component of such a system will be the availability of international standards for foetal growth and neonatal weight, length and head circumference for gestational age. Such standards should follow the prescriptive conceptual approach used to construct the WHO Child Growth Standards currently used worldwide. However, their utility depends on accurate measurement of weight, length and head circumference at birth, which is rare in LMICs. In these settings, in which either a large proportion of pregnant women do not have access to antenatal care or many births occur in the home, valid estimates of gestational age and accurate anthropometry birth measurements are difficult or impossible to obtain. Nevertheless, in an ideal world, their availability would enable us to move beyond the traditional maternal and child health indicator of low birthweight (<2500 g) which, as shown by Lee and colleagues, fails to identify most babies who are born either too small or too soon. The new evidence from Christian and colleagues is both timely and important. Timely, because it comes at a moment when international mobilization around malnutrition has never been stronger, in particular with the Scaling Up Nutrition (SUN) movement (http://scalingupnutrition.org). Important, because it shows that efforts to tackle the scourge of undernutrition and its perverse effects on human health and development will not succeed without paying Published by Oxford University Press on behalf of the International Epidemiological Association