Reduction In Low Birth Weight Research Articles

Vitamin and Mineral Supplementation During Pregnancy on Maternal, Birth, Child Health and Development Outcomes in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis.

Almost two billion people are deficient in key vitamins and minerals, mostly women and children in low- and middle-income countries (LMICs). Deficiencies worsen during pregnancy due to increased energy and nutritional demands, causing adverse outcomes in mother and child, but could be mitigated by interventions like micronutrient supplementation. To our knowledge, this is the first systematic review that aimed to compile evidence from both efficacy and effectiveness trials, evaluating different supplementation interventions on maternal, birth, child health, and developmental outcomes. We evaluated randomized controlled trials and quasi-experimental studies published since 1995 in peer-reviewed and grey literature that assessed the effects of calcium, vitamin A, iron, vitamin D, and zinc supplementation compared to placebo/no treatment; iron-folic (IFA) supplementation compared to folic acid only; multiple micronutrient (MMN) supplementation compared to IFA; and lipid-based nutrient supplementation (LNS) compared to MMN supplementation. Seventy-two studies, which collectively involved 314 papers (451,723 women), were included. Meta-analyses showed improvement in several key birth outcomes, such as preterm birth, small-for-gestational age (SGA) and low birthweight with MMN supplementation, compared to IFA. MMN also improved child outcomes, including diarrhea incidence and retinol concentration, which are findings not previously reported. Across all comparisons, micronutrient supplementation had little to no effect on mortality (maternal, neonatal, perinatal, and infant) outcomes, which is consistent with other systematic reviews. IFA supplementation showed notable improvement in maternal anemia and the reduction in low birthweight, whereas LNS supplementation had no apparent effect on outcomes; further research that compares LNS and MMN supplementation could help understand differences with these commodities. For single micronutrient supplementation, improvements were noted in only a few outcomes, mainly pre-eclampsia/eclampsia (calcium), maternal anemia (iron), preterm births (vitamin D), and maternal serum zinc concentration (zinc). These findings highlight that micronutrient-specific supplementation should be tailored to specific groups or needs for maximum benefit. In addition, they further contribute to the ongoing discourse of choosing antenatal MMN over IFA as the standard of care in LMICs.

Effect of Plasmodium falciparum sulfadoxine-pyrimethamine resistance on the effectiveness of intermittent preventive therapy for malaria in pregnancy in Africa: a systematic review and meta-analysis

Resistance of Plasmodium falciparum to sulfadoxine-pyrimethamine threatens the antimalarial effectiveness of intermittent preventive treatment during pregnancy (IPTp) in sub-Saharan Africa. We aimed to assess the associations between markers of sulfadoxine-pyrimethamine resistance in P falciparum and the effectiveness of sulfadoxine-pyrimethamine IPTp for malaria-associated outcomes. For this systematic review and meta-analysis, we searched databases (from Jan 1, 1990 to March 1, 2018) for clinical studies (aggregated data) or surveys (individual participant data) that reported data on low birthweight (primary outcome) and malaria by sulfadoxine-pyrimethamine IPTp dose, and for studies that reported on molecular markers of sulfadoxine-pyrimethamine resistance. Studies that involved only HIV-infected women or combined interventions were excluded. We did a random-effects meta-analysis (clinical studies) or multivariate log-binomial regression (surveys) to obtain summarised dose-response data (relative risk reduction [RRR]) and multivariate meta-regression to explore the modifying effects of sulfadoxine-pyrimethamine resistance (as indicated by Ala437Gly, Lys540Glu, and Ala581Gly substitutions in the dhps gene). This study is registered with PROSPERO, number 42016035540. Of 1097 records screened, 57 studies were included in the aggregated-data meta-analysis (including 59 457 births). The RRR for low birthweight declined with increasing prevalence of dhps Lys540Glu (ptrend=0·0060) but not Ala437Gly (ptrend=0·35). The RRR was 7% (95% CI 0 to 13) in areas of high resistance to sulfadoxine-pyrimethamine (Lys540Glu ≥90% in east and southern Africa; n=11), 21% (14 to 29) in moderate-resistance areas (Ala437Gly ≥90% [central and west Africa], or Lys540Glu ≥30% to <90% [east and southern Africa]; n=16), and 27% (21 to 33) in low-resistance areas (Ala437Gly <90% [central and west Africa], or Lys540Glu <30% [east and southern Africa]; n=30; ptrend=0·0054 [univariate], I2=69·5%). The overall RRR in all resistance strata was 21% (17 to 25). In the analysis of individual participant data from 13 surveys (42 394 births), sulfadoxine-pyrimethamine IPTp was associated with reduced prevalence of low birthweight in areas with a Lys540Glu prevalence of more than 90% and Ala581Gly prevalence of less than 10% (RRR 10% [7 to 12]), but not in those with an Ala581Gly prevalence of 10% or higher (pooled Ala581Gly prevalence 37% [range 29 to 46]; RRR 0·5% [-16 to 14]; 2326 births). The effectiveness of sulfadoxine-pyrimethamine IPTp is reduced in areas with high resistance to sulfadoxine-pyrimethamine among P falciparum parasites, but remains associated with reductions in low birthweight even in areas where dhps Lys540Glu prevalence exceeds 90% but where the sextuple-mutant parasite (harbouring the additional dhps Ala581Gly mutation) is uncommon. Therapeutic alternatives to sulfadoxine-pyrimethamine IPTp are needed in areas where the prevalence of the sextuple-mutant parasite exceeds 37%. US Centers for Disease Control and Prevention, the Malaria in Pregnancy Consortium (funded through a grant from the Bill & Melinda Gates Foundation to the Liverpool School of Tropical Medicine), Worldwide Antimalarial Resistance Network, European and Developing Countries Clinical Trials Partnership.

Associação entre qualidade do pré-natal e baixo peso ao nascer em uma instituição hospitalar em Feira de Santana / BA

Justificativa e Objetivo: Estudos apontam que a maior adesão ao pré-natal esteja diretamente ligada a redução do baixo peso ao nascer (BPN), sendo que, a deficiência do primeiro seja uma das maiores causas do segundo. Dessa forma, este estudo objetivou medir a associação entre qualidade do pré-natal (QPN) e BPN em usuárias de um hospital em Feira de Santana/BA. Métodos: Realizou-se um estudo caso-controle com 144 mulheres internadas na maternidade para realização de parto. Para coleta de dados foi utilizado o cartão da gestante, prontuário hospitalar e aplicação de questionários. Foram obtidas odds ratio (OR) para comparação dos grupos e procedida análise multivariada para estimar o efeito da QPN no BPN. Resultados: Foi encontrada uma prevalência de 18,8% de recém-nascidos &lt; 2500g. Após o ajuste para confundimento, a QPN mostrou um efeito independente para BPN (ORajustada= 2,56; IC 95%: 1,05 – 6,20, p = 0,02). Conclusão: A pesquisa reafirma a importância da priorização de um pré-natal eficaz, como um fator que pode contribuir na redução do BPN.

Modifiers of the effect of maternal multiple micronutrient supplementation on stillbirth, birth outcomes, and infant mortality: a meta-analysis of individual patient data from 17 randomised trials in low-income and middle-income countries.

Micronutrient deficiencies are common among women in low-income and middle-income countries. Data from randomised trials suggest that maternal multiple micronutrient supplementation decreases the risk of low birthweight and potentially improves other infant health outcomes. However, heterogeneity across studies suggests influence from effect modifiers. We aimed to identify individual-level modifiers of the effect of multiple micronutrient supplements on stillbirth, birth outcomes, and infant mortality in low-income and middle-income countries. This two-stage meta-analysis of individual patient included data from 17 randomised controlled trials done in 14 low-income and middle-income countries, which compared multiple micronutrient supplements containing iron-folic acid versus iron-folic acid alone in 112 953 pregnant women. We generated study-specific estimates and pooled subgroup estimates using fixed-effects models and assessed heterogeneity between subgroups with the χ2 test for heterogeneity. We did sensitivity analyses using random-effects models, stratifying by iron-folic acid dose, and exploring individual study effect. Multiple micronutrient supplements containing iron-folic acid provided significantly greater reductions in neonatal mortality for female neonates compared with male neonates than did iron-folic acid supplementation alone (RR 0·85, 95% CI 0·75-0·96 vs 1·06, 0·95-1·17; p value for interaction 0·007). Multiple micronutrient supplements resulted in greater reductions in low birthweight (RR 0·81, 95% CI 0·74-0·89; p value for interaction 0·049), small-for-gestational-age births (0·92, 0·87-0·97; p=0·03), and 6-month mortality (0·71, 0·60-0·86; p=0·04) in anaemic pregnant women (haemoglobin <110g/L) as compared with non-anaemic pregnant women. Multiple micronutrient supplements also had a greater effect on preterm births among underweight pregnant women (BMI <18·5 kg/m2; RR 0·84, 95% CI 0·78-0·91; p=0·01). Initiation of multiple micronutrient supplements before 20 weeks gestation provided greater reductions in preterm birth (RR 0·89, 95% CI 0·85-0·93; p=0·03). Generally, the survival and birth outcome effects of multiple micronutrient supplementation were greater with high adherence (≥95%) to supplementation. Multiple micronutrient supplements did not significantly increase the risk of stillbirth or neonatal, 6-month, or infant mortality, neither overall or in any of the 26 examined subgroups. Antenatal multiple micronutrient supplements improved survival for female neonates and provided greater birth-outcome benefits for infants born to undernourished and anaemic pregnant women. Early initiation in pregnancy and high adherence to multiple micronutrient supplements also provided greater overall benefits. Studies should now aim to elucidate the mechanisms accounting for differences in the effect of antenatal multiple micronutrient supplements on infant health by maternal nutrition status and sex. None.

No Strings Attached: Evaluating an Unconditional Prenatal Income Supplement Using Linked Administrative Data

ABSTRACT&#x0D; ObjectivePerinatal outcomes have improved overall in developed countries over the last several decades but remain poor for disadvantaged populations. In Manitoba, Canada, the Healthy Baby Prenatal Benefit (HBPB), a cash transfer to low-income pregnant women, was introduced with the goal of improving perinatal outcomes. The objective of this study was to use linked administrative and program datasets to determine whether this unconditional income supplement was associated with improved birth outcomes for a low-income population.&#x0D; ApproachThis study used data from the PATHS Data Resource, which contains population-level health and social service records as well as program data for approximately 600,000 children in Manitoba, Canada, over a 30-year period, linkable at the individual level. All mother-newborn pairs, from 2003-2010, who met the following criteria were included for analyses: i) the mother was on social assistance (i.e., low income); ii) the infant was born in hospital; and, iii) the pair had a newborn risk screen (n=14,591), documenting factors such as prenatal alcohol and tobacco exposure and maternal and family characteristics. Low-income women who received HBPB (exposed, 10,738) were compared with low-income women who did not receive HBPB (unexposed, 3,853) on several outcomes: low birth weight, preterm, small- and large-for-gestational age, 5-minutes Apgar scores, breastfeeding initiation, neonatal readmission, and newborn hospital length of stay (LOS). Covariates from the risk screens were used to develop propensity scores to construct Inverse Probability of Treatment Weights, to balance differences between exposed and unexposed groups in regression models. Gamma sensitivity analyses assessed sensitivity to unmeasured confounding. Population attributable and preventable fractions were calculated.&#x0D; ResultsHBPB exposure was associated with reductions in low birth weight (adjusted risk ratio, aRR=0.71, 95% CI=0.63, 0.81), preterm (aRR=0.76 (0.69, 0.84)) and small-for-gestational age (aRR=0.90 (0.81, 0.99)) births and increases in breastfeeding (aRR=1.06 (1.03, 1.09)) and large-for-gestational age births (aRR=1.13 (1.05, 1.23)). For vaginal births, HBPB was associated with shortened LOS (mean=2.86, p&lt;0.0001). Results for breastfeeding, low birth weight, preterm and LOS were robust to unmeasured confounding. Reductions of 21% (95% CI 13.6, 28.3) of low birth weight and 17.5% (11.2, 23.8) of preterm were associated with receipt of the HBPB.&#x0D; ConclusionsA modest income supplement during pregnancy was associated with improved birth outcomes for infants born to low-income women. Placing conditions on income supplements to low income pregnant women may not be necessary to promote prenatal and perinatal health. Linked administrative data can be a valuable tool for program evaluation.

Unconditional Prenatal Income Supplement and Birth Outcomes.

Perinatal outcomes have improved in developed countries but remain poor for disadvantaged populations. We examined whether an unconditional income supplement to low-income pregnant women was associated with improved birth outcomes. This study included all mother-newborn pairs (2003-2010) in Manitoba, Canada, where the mother received prenatal social assistance, the infant was born in the hospital, and the pair had a risk screen (N = 14 591). Low-income women who received the income supplement (Healthy Baby Prenatal Benefit [HBPB], n = 10 738) were compared with low-income women who did not receive HBPB (n = 3853) on the following factors: low birth weight, preterm, small and large for gestational age, Apgar score, breastfeeding initiation, neonatal readmission, and newborn hospital length of stay (LOS). Covariates from risk screens were used to develop propensity scores and to balance differences between groups in regression models; γ sensitivity analyses were conducted to assess sensitivity to unmeasured confounding. Population-attributable and preventable fractions were calculated. HBPB was associated with reductions in low birth weight (aRR, 0.71 [95% CI, 0.63-0.81]), preterm births (aRR, 0.76 [95% CI, 0.69-0.84]) and small for gestational age births (aRR, 0.90 [95% CI, 0.81-0.99]) and increases in breastfeeding (aRR, 1.06 [95% CI, 1.03-1.09]) and large for gestational age births (aRR, 1.13 [95% CI, 1.05-1.23]). For vaginal births, HBPB was associated with shortened LOS (weighted mean, 2.86; P < .0001). Results for breastfeeding, low birth weight, preterm birth, and LOS were robust to unmeasured confounding. Reductions of 21% (95% CI, 13.6-28.3) for low birth weight births and 17.5% (95% CI, 11.2-23.8) for preterm births were associated with HBPB. Receipt of an unconditional prenatal income supplement was associated with positive outcomes. Placing conditions on income supplements may not be necessary to promote prenatal and perinatal health.

Associations of gender inequality with child malnutrition and mortality across 96 countries.

National efforts to reduce low birth weight (LBW) and child malnutrition and mortality prioritise economic growth. However, this may be ineffective, while rising gross domestic product (GDP) also imposes health costs, such as obesity and non-communicable disease. There is a need to identify other potential routes for improving child health. We investigated associations of the Gender Inequality Index (GII), a national marker of women's disadvantages in reproductive health, empowerment and labour market participation, with the prevalence of LBW, child malnutrition (stunting and wasting) and mortality under 5 years in 96 countries, adjusting for national GDP. The GII displaced GDP as a predictor of LBW, explaining 36% of the variance. Independent of GDP, the GII explained 10% of the variance in wasting and stunting and 41% of the variance in child mortality. Simulations indicated that reducing GII could lead to major reductions in LBW, child malnutrition and mortality in low- and middle-income countries. Independent of national wealth, reducing women's disempowerment relative to men may reduce LBW and promote child nutritional status and survival. Longitudinal studies are now needed to evaluate the impact of efforts to reduce societal gender inequality.

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.

Impact of smoke-free legislation on perinatal and infant mortality: a national quasi-experimental study.

Smoke-free legislation is associated with improved early-life outcomes; however its impact on perinatal survival is unclear. We linked individual-level data with death certificates for all registered singletons births in England (1995–2011). We used interrupted time series logistic regression analysis to study changes in key adverse perinatal events following the July 2007 national, comprehensive smoke-free legislation. We studied 52,163 stillbirths and 10,238,950 live-births. Smoke-free legislation was associated with an immediate 7.8% (95%CI 3.5–11.8; p < 0.001) reduction in stillbirth, a 3.9% (95%CI 2.6–5.1; p < 0.001) reduction in low birth weight, and a 7.6% (95%CI 3.4–11.7; p = 0.001) reduction in neonatal mortality. No significant impact on SIDS was observed. Using a counterfactual scenario, we estimated that in the first four years following smoke-free legislation, 991 stillbirths, 5,470 cases of low birth weight, and 430 neonatal deaths were prevented. In conclusion, smoke-free legislation in England was associated with clinically important reductions in severe adverse perinatal outcomes.

Antibiotics for asymptomatic bacteriuria in pregnancy.

Asymptomatic bacteriuria occurs in 2% to 10% of pregnancies and, if not treated, up to 30% of mothers will develop acute pyelonephritis. Asymptomatic bacteriuria has been associated with low birthweight and preterm birth. To assess the effect of antibiotic treatment for asymptomatic bacteriuria on the development of pyelonephritis and the risk of low birthweight and preterm birth. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (19 March 2015) and reference lists of retrieved studies. Randomized trials comparing antibiotic treatment with placebo or no treatment in pregnant women with asymptomatic bacteriuria found on antenatal screening. Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Fourteen studies, involving almost 2000 women, were included. Antibiotic treatment compared with placebo or no treatment reduced the incidence of pyelonephritis (average risk ratio (RR) 0.23, 95% confidence interval (CI) 0.13 to 0.41; 11 studies, 1932 women; very low quality evidence). Antibiotic treatment was also associated with a reduction in the incidence of low birthweight babies (average RR 0.64, 95% CI 0.45 to 0.93; six studies, 1437 babies; low quality evidence) and preterm birth (RR 0.27, 95% CI 0.11 to 0.62; two studies, 242 women; low quality evidence). A reduction in persistent bacteriuria at the time of delivery was seen (average RR 0.30, 95% CI 0.18 to 0.53; four studies; 596 women). There were very limited data on which to estimate the effect of antibiotics on other infant outcomes and maternal adverse effects were rarely described.Overall, all 14 studies were assessed as being at high or unclear risk of bias. While many studies lacked an adequate description of methods and the risk of bias could only be assessed as unclear, in almost all studies there was at least one domain where the risk of bias was judged as high. The three primary outcomes were assessed with GRADE software and given a quality rating. Evidence for pyelonephritis, preterm birth and birthweight less than 2500 g was assessed as of low or very low quality. While antibiotic treatment is effective in reducing the risk of pyelonephritis in pregnancy, the estimate of the effect is very uncertain because of the very low quality of the evidence. The reduction in low birthweight and preterm birth with antibiotic treatment is consistent with theories about the role of infection in adverse pregnancy outcomes, but this association should be interpreted with caution given the very poor quality of the included studies.

Smoke-free legislation improves child health.

Journal of Paediatrics and Child HealthVolume 51, Issue 5 p. 565-565 Heads UpFree Access Smoke-free legislation improves child health First published: 03 May 2015 https://doi.org/10.1111/jpc.12900_4AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Smoking kills an estimated 5.7 million people each year. It is estimated that 600 000 of these deaths and 10.9 million disability-adjusted life years are a result of second-hand smoke exposure (passive smoking). The World Health Organization (WHO) Framework Convention for Tobacco Control has been ratified by 177 countries, but comprehensive smoke-free laws only cover 16% of the world's population. A systematic review of the efficacy of smoke-free legislation on perinatal and child health (preterm birth, low birthweight and asthma) identified 11 studies, all of which used interrupted time series.1 One study had a high risk of bias, six moderate and four low. Five North American studies described local bans and six European studies were of national bans. Smoke-free legislation was significantly associated with a 10.4% reduction in preterm birth (95% confidence interval (CI) 2.0 to 18.8%) and a 10.1% reduction in hospital admissions for asthma (95% CI 5.0 to 15.2%) but no significant reduction in low birthweight. This analysis gives strong support to the WHO recommendations on smoke-free legislation. Reference 1Been JV et al. Lancet 2014; 383: 1549– 1560. CrossrefPubMedWeb of Science®Google Scholar Reviewer: David Isaacs, david.isaacs@health.nsw.gov.au Volume51, Issue5May 2015Pages 565-565 ReferencesRelatedInformation

Within-Mother Estimates of the Effects of WIC on Birth Outcomes in New York City.

There is a large literature suggesting that "WIC works" to improve birth outcomes. However, methodological limitations related to selection into the WIC program have left room for doubt about this conclusion. This paper uses birth records from New York City to address some limitations of the previous literature. We estimate models with mother fixed effects to control for fixed characteristics of mothers and we directly investigate the way that time-varying characteristics of mothers affect selection into the WIC program. We find that WIC is associated with reductions in low birth weight, even among full term infants, and with reductions in the probability that a child is "small for dates." These improvements are associated with a reduction in the probability that the mother gained too little weight during pregnancy. Improvements tend to be largest for first born children. We also find that women on WIC are more likely to be diagnosed with chronic conditions, and receive more intensive medical services, a finding that may reflect improved access to medical care.

The impact of diabetes insurance mandates on infant health

Among the factors thought to contribute to lagging improvements in infant health in recent years are increasing obesity and diabetes prevalence among women of childbearing age. This article uses a difference‐in‐difference‐in‐difference empirical strategy to investigate the impact of mandated insurance coverage for diabetes on adverse pregnancy outcomes. Among educated women, who have high rates of coverage through private insurance that is subject to insurance mandates, diabetes mandates are associated with a reduction in low birth weight and premature birth prevalence. These gains are concentrated among older women and are larger for African‐Americans. There is a weaker effect on the prevalence of high birth weight, potentially because of the deleterious effects of an increased probability of pregnancy weight gain in excess of 35 pounds among diabetic women in states with mandates.

Prevalence and determinants of low birth weight and prematurity among rural, urban, and indigenous tribal communities in India.

Background: Birth weight and gestational age are important determinants of child survival and development. Developing countries like India have been recording very high prevalence (30-40%) of low birth weight (LBW) and a relatively low prevalence of prematurity (~10%). Aim: Examine the role of multiple environmental factors on neonatal outcomes in India. Methods: Utilizing a population-based, 6884 mother-baby cohort spread across rural, tribal, and urban areas of Odisha, we have recently launched the IMMENSE (Impact of Maternal Environmental and Socio Economic - status on child health and development) study where data are being collected on maternal variables and on type of household cooking fuel, direct smoke and ETS, drinking water, alcohol use, and exposure to occupational/industrial/ and mining and pesticides and fertilizers, New births are also being added to this cohort. Results: Average gestational age in this population was 32 weeks and birth weight was 2.53 kg. A total of 28% babies were premature; 13.3% ? 35 weeks, and an additional 14.8% between 36-40 weeks of gestation. The decrements in birth weight were attenuated using multivariate analyses after adjusting the maternal and socioeconomic factors. The environmental factors significantly associated with LBW were biomass fuel/household air pollution (OR-2.51), drinking water (OR-2.34), proximity to industry/highway (OR-1.98), domestic/agricultural pesticide use (OR-1.91), smoking/ETS (OR-1.85), and alcohol use (OR-1.39). Although small in number, newborns in households using liquid petroleum gas did not seem to have better outcomes. Conclusions: This study demonstrates an unexpected shift from low birth weight preponderance to an increase in prematurity in India (similar to the western countries). While improved maternal health over the decades might have contributed to reduction in LBW, new and significant environmental pollution may be contributing to preterm births. The IMMENSE study was funded by a grant from the University of Nebraska Foundation.

Weighing for results: assessing the effect of IPTp

Although earlier studies showed that intermittent preventive therapy in pregnancy (IPTp) with sulfadoxine–pyrimethamine provides substantial benefit to pregnant women and their infants, the spread of resistance raises questions about how long the therapy is efficient for.1 In their meta-analysis, Thomas Eisele and colleagues2 show that IPTp with sulfadoxine–pyrimethamine continues to provide substantial benefits, resulting in a 26% reduction in low birthweight and a 16% reduction in neonatal mortality under programme conditions.

Maternal Characteristics and Temporal Trends in Birth Outcomes: Comparison between Spanish and Migrant Mothers

Low birth weight and preterm babies have been increasing in Spain since 1980, coinciding with important changes in the social and demographic structure of childbearing populations—including the contribution of a 25% of foreign mothers—and with increasing medical intervention in births. This study, based on 5,990,613 births, compares the temporary trends in reproductive patterns and birth outcomes in Spanish and foreign mothers during the period 1996–2009 and evaluates for the years 2007 to 2009 the relative contribution of mother's origin and Caesarean section to birth weight variability. Foreign mothers maintain their own reproductive pattern, whereas negative birth outcomes increase in all groups. Results from logistic regression analysis show that besides late maternity and primiparity also Caesarean section increases the risk for low birth weight. The reduction in Caesarean section rates between 2007 and 2009 might explain the reduction of low birth weight detected. A change of tendency simultaneously appears in most maternal and newborn characteristics, and in the mode of delivery in all ethnic groups since 2008. Coincidence in the timing of the change of trends points to a common factor. We suggest that the current world financial crisis could be this common cause, a hypothesis to be contrasted in future research.

Evidence for Multiple Micronutrient Effects Based on Randomized Controlled Trials and Meta-Analyses in Developing Countries ,

Providing multiple micronutrients via supplements, powders, or fortified ready-to-use foods is increasingly becoming a strategy for simultaneously addressing multiple nutrient deficiencies in developing countries. The pros and cons of the “gold standard” randomized controlled trial (RCT) design and meta-analyses of trials for establishing efficacy of nutritional interventions are discussed. Over the past decade, numerous RCT have been undertaken to test the efficacy of multiple micronutrient supplementation in both pregnant women and young children. Outcomes of interest have ranged from birth weight to child growth, and infant morbidity and mortality to nutrient status and cognitive function. These RCT have also been submitted to meta-analyses for estimating pooled effect sizes for various outcomes. Meta-analyses of antenatal multiple micronutrient supplementation reveal a modest but significant increase in birth weight of 22.4 g (95% CI: 8.3, 36.4 g) and an 11% (95% CI: 3, 19) reduction in low birth weight but no impact on preterm birth or perinatal mortality. In children, small effect sizes of 0.13 (95% CI: 0.06, 0.21) for length/height and 0.14 (95% CI: 0.03, 0.25) for weight have been shown with 3 or more micronutrients compared to fewer micronutrients, but there is limited evidence for an impact on outcomes such as morbidity and cognitive function. Gaps in research and future challenges for programmatic application of this strategy for both pregnant women and young children are discussed.

Modifying Effects of Wealth on the Response to Nutrient Supplementation in Pregnancy on Birth Weight, Duration of Gestation, and Perinatal Mortality in Rural Western China: Double-Blind Cluster Randomized Controlled Trial

It has been suggested that neonatal outcomes may differ between pregnant women from poor households and wealthier households receiving nutrient supplementation. A cluster randomized controlled trial found significantly lower dietary intakes of iron (as well as other micronutrients) among pregnant women in rural China from poor households than among those from wealthy households. Antenatal treatment with both iron/folic acid and multiple micronutrient (MMN) supplementation compared with folic acid alone was associated with increased duration of gestation, reduced early preterm delivery (<34 weeks of gestation), and significant reduction in early neonatal mortality. This study investigated the role of differences in household wealth on the effects of antenatal micronutrient supplements on birth anthropometry, duration of gestation, and perinatal mortality. Data were obtained from secondary analysis of a previously published cluster randomized controlled trial conducted in rural China on women during pregnancy, which examined the impact of iron/folic acid and MMN supplements compared with folic acid alone on several maternal/fetal outcomes. A total of 5828 eligible pregnant women were randomized to receive daily supplementation with folic acid (control), iron/folic acid, or MMNs until delivery. Ownership of household assets or facilities was used to construct a wealth index to indicate the poorest, middle, and the wealthiest households. Compared with folic acid, MMN supplementation in pregnant women from the 4 households was associated with a 68-g increase in birth weight (95% confidence interval [CI], 4–131; P < 0.037), a 60% reduction in low birth weight (relative risks [RR], 0.40; 95% CI, 0.21–0.78; P < 0.007), and a tendency toward 52% reduction in early neonatal mortality (RR, 0.48; 95% CI, 0.17–1.36). In comparison with folic acid, women from the poorest households receiving iron/folic acid supplements had a 90% reduction in the risk of early neonatal mortality (RR, 0.10; 95% CI, 0.01–0.79), an increase in duration of gestation by 0.41 weeks (95% CI, 0.18–0.65), and a 45% reduction in preterm birth (RR, 0.55; 95% CI, 0.32–0.93). In contrast, neither iron/folic acid nor MMN supplements had significant effects in women from wealthier households. These findings show that antenatal micronutrient supplementation is associated with a significant improvement in perinatal outcomes among pregnant Chinese women from the poorest households, but not among those from the wealthiest households.

Preventing Low Birthweight: 25 years, prenatal risk, and the failure to reinvent prenatal care

In 2010, Preventing Low Birthweight celebrated it 25th anniversary. The report, one of the most influential policy statements ever issued regarding obstetric health care delivery, linked prenatal care to a reduction in low birthweight (LBW). Medicaid coverage for prenatal care services was subsequently expanded and resulted in increased prenatal care utilization. However, the rate of LBW failed to decrease. This well-intentioned expansion of prenatal care services did not change the structure of prenatal care. A single, standardized prenatal care model, largely ineffective in the prevention of LBW, was expanded to a heterogeneous group of patients with a variety of medical and psychosocial risk factors. Reinventing prenatal care as a flexible model, with content, frequency, and timing tailored to maternal and fetal risk, may improve adverse birth outcomes. Risk-appropriate prenatal care may improve the effectiveness of prenatal care for high-risk patients and the efficiency of prenatal care delivery for low-risk patients.

Effectiveness of intermittent preventive treatment with sulphadoxine-pyrimethamine and insecticide treated nets on the prevention of malaria in pregnancy in non-malarial endemic area in Kenya

Background: Malaria prevention strategies have significantly reduced the prevalence of malaria in pregnant women in several studies done in malaria endemic regions. Objective: To determine the effectiveness of Intermittent preventive treatment with sulphadoxine-pyrimethamine and Insecticide treated nets on the prevention of malaria in pregnancy in a non-malaria endemic area. Design: Comparative study. Setting: Kapsabet District Hospital in Nandi County. Subjects: One hundred and fourty three non-randomised pregnant women were followed through the Antenatal clinic before 28 weeks gestation until delivery and compared with records of 600 pregnant women ( non-intervention arm), who attended ANC and delivered at the hospital. Results: The incidence of malaria infection in pregnancy was 21% in the non-intervention group compared with 8% in the intervention group, (p-value 0.000). The incidence of low birth weight was 12.5% in the non-intervention group compared with 5.6% in the intervention group (p-value 0.018); with a reduction of low birth weight by 50% in the intervention group. The incidence of Still births was 6% in the non-intervention group and 1.4% in the intervention group (p-value 0.025). There were two (0.3%) cases of maternal mortality in the non-intervention group and no mortality in the intervention group which was statistically not significant but clinically significant. Conclusion: The use of intermittent preventive treatment with sulphadoxinepyrimethamine and Insecticide Treated Nets is effective in prevention of malaria in pregnancy in non-malaria endemic region and is associated with reduction of adverse pregnancy outcome. There is therefore a need of up scaling the use of sulphadoxinepyrimethamine during pregnancy, and availing subsidised long lasting insecticide treated bed nets to pregnant women countrywide.