Urban Births Research Articles

Obstetric Volume and Severe Maternal Morbidity Among Low-Risk and Higher-Risk Patients Giving Birth at Rural and Urban US Hospitals

ImportanceIdentifying hospital factors associated with severe maternal morbidity (SMM) is essential to clinical and policy efforts.ObjectiveTo assess associations between obstetric volume and SMM in rural and urban hospitals and examine whether these associations differ for low-risk and higher-risk patients.Design, Setting, and ParticipantsThis retrospective cross-sectional study of linked vital statistics and patient discharge data was conducted from 2022 to 2023. Live births and stillbirths (≥20 weeks’ gestation) at hospitals in California (2004-2018), Michigan (2004-2020), Pennsylvania (2004-2014), and South Carolina (2004-2020) were included. Data were analyzed from December 2022 to May 2023.ExposuresAnnual birth volume categories (low, medium, medium-high, and high) for hospitals in urban (10-500, 501-1000, 1001-2000, and >2000) and rural (10-110, 111-240, 241-460, and >460) counties.Main Outcome and MeasuresThe main outcome was SMM (excluding blood transfusion); covariates included age, payer status, educational attainment, race and ethnicity, and obstetric comorbidities. Analyses were stratified for low-risk and higher-risk obstetric patients based on presence of at least 1 clinical comorbidity.ResultsAmong more than 11 million urban births and 519 953 rural births, rates of SMM ranged from 0.73% to 0.50% across urban hospital volume categories (high to low) and from 0.47% to 0.70% across rural hospital volume categories (high to low). Risk of SMM was elevated for patients who gave birth at rural hospitals with annual birth volume of 10 to 110 (adjusted risk ratio [ARR], 1.65; 95% CI, 1.14-2.39), 111 to 240 (ARR, 1.37; 95% CI, 1.10-1.70), and 241 to 460 (ARR, 1.26; 95% CI, 1.05-1.51), compared with rural hospitals with greater than 460 births. Increased risk of SMM occurred for low-risk and higher-risk obstetric patients who delivered at rural hospitals with lower birth volumes, with low-risk rural patients having notable discrepancies in SMM risk between low (ARR, 2.32; 95% CI, 1.32-4.07), medium (ARR, 1.66; 95% CI, 1.20-2.28), and medium-high (ARR, 1.68; 95% CI, 1.29-2.18) volume hospitals compared with high volume (>460 births) rural hospitals. Among hospitals in urban counties, there was no significant association between birth volume and SMM for low-risk or higher-risk obstetric patients.Conclusions and RelevanceIn this cross-sectional study of births in US rural and urban counties, risk of SMM was elevated for low-risk and higher-risk obstetric patients who gave birth in lower-volume hospitals in rural counties, compared with similar patients who gave birth at rural hospitals with greater than 460 annual births. These findings imply a need for tailored quality improvement strategies for lower volume hospitals in rural communities.

Absence of family support and associated factors in the urban births of a city in Southern Brazil: fact or fiction?

RESUMO Objetivo: Verificar a prevalência e identificar os fatores associados à ausência do acompanhante de parto em mulheres no sul do Brasil. Métodos: Trata-se de um estudo transversal, realizado com 466 parturientes, pertencentes a uma coorte de mulheres da zona urbana da cidade de Pelotas, RS. Aos 18 meses pós-parto, foi aplicado um questionário estruturado com dados sociodemográficos, gestacionais e questões relacionadas ao parto. Foi realizada regressão logística para ajustes de possíveis fatores de confusão. Resultados: A prevalência da ausência de acompanhante de parto entre as mulheres foi de 22,3%. As parturientes com até 8 anos de estudo (RP=2,0 [IC95% 1,1–3,8]), que não viviam com um companheiro (RP=2,3 [IC95% 1,2–4,3]), que realizaram o pré-natal no setor público (RP=1,9 [IC95% 1,0–3,7]) e que tiveram um parto via cesárea (RP=6,0 [IC95% 2,9–12,4]) apresentaram maior probabilidade de ausência de acompanhante de parto. Conclusão: Os resultados apontam evidências relevantes para o seguimento da verificação da presença do acompanhante de parto no sul do Brasil, indicando a necessidade de melhor aproveitamento e adesão desta prática. Além disso, a lei que aprova a presença do acompanhante de parto no Brasil parece não estar sendo colocada em prática de modo integral, desrespeitando um direito das parturientes e impactando nos benefícios para a saúde materno-infantil.

Out-of-hospital births and infant mortality in the United States: Effect measure modification by rural maternal residence.

Out-of-hospital births have been increasing in the United States, and home births are almost twice as common in rural vs. urban counties. Planned home births and births in rural areas have each been associated with an increased risk of infant mortality. To estimate the effect of birth setting on infant mortality in the United States and how this is modified by rural-urban county of maternal residence. We conducted a population-based cohort study of infants born in the United States during 2010-2017 using the National Center for Health Statistics' period-linked birth-infant death files. Unadjusted and adjusted Poisson regression models were used to calculate infant mortality rate ratios and 95% confidence intervals for out-of-hospital births vs. hospital births stratified by maternal residence. Relative excess risk due to interaction (RERI) was calculated to assess effect measure modification on the additive scale. The study included 25,210,263live births. Of rural births, 97.8% was in hospitals, 0.5% was in birth centres, and 1.5% was planned home births; of urban births, 98.6% was in hospitals, 0.5% was in birth centres, and 0.7% was planned home births. After adjusting for maternal demographics and markers of high-risk pregnancy and stratifying by maternal residence, infant mortality rates were generally higher for out-of-hospital as compared to hospital births (e.g. rural planned home births aRR1.62, 95% confidence interval [CI] 1.42, 1.85, and rural birth centre aRR1.33, 95% CI 1.05, 1.68). There were positive additive effects of rural residence on infant mortality for planned home births and birth centre births. Within both rural and urban areas, out-of-hospital births generally had higher rates of infant mortality than hospital births after accounting for maternal demographics and markers of high-risk pregnancy. The risks associated with planned home births and birth centre births were more pronounced for women in rural counties.

Residential inequality and spatial patterns of infant mortality in Ethiopia: evidence from Ethiopian Demographic and Health Surveys

BackgroundDespite the remarkable decrease in infant mortality rate in most countries, the rate of decline is slow and it remains unacceptably high in Sub-Saharan Africa. The progress in infant mortality in Ethiopia is far below the rate needed to achieve the Sustainable Development Goal. Understanding the residential inequality and spatiotemporal clusters of infant mortality is essential to prioritize areas and guide public health interventions. Therefore, this study aimed to investigate the residential inequality and spatial patterns of infant mortality in Ethiopia.MethodsA secondary data analysis was done based on the Ethiopian demographic and health surveys conducted in 2000, 2005, 2011, and 2016. A total weighted sample of 46,317 live births was included for the final analysis. The residential inequality was assessed by calculating the risk difference in infant mortality rates between urban and rural live births and presented using a forest plot. For the spatial patterns of infant mortality, the SaTScan version 9.6 and ArcGIS version 10.6 statistical software were used to identify the spatial patterns of infant mortality.ResultsThe study revealed that the infant mortality rate significantly declined from 96.9 per 1000 live births [95% CI 93.6, 104.2] in 2000 to 48.0 per 1000 live births [95% CI 44.2, 52.2] in 2016 with an annual rate of reduction of 3.2%. The infant mortality rate has substantial residential inequality over time, which is concentrated in the rural area. The spatial distribution of infant mortality was significantly clustered at the national level in survey periods (global Moran’s I, 0.04–0.081, p value < 0.05). In 2000, the most likely clusters were found in east Afar and at the border areas of south Amhara and north Oromia regions (LLR = 7.61, p value < 0.05); in 2005, at the border areas of Southern Nations Nationalities and People and in the entire Amhara region (LLR = 10.78, p value< 0.05); in 2011, at Southern Nations Nationalities and People and Gambella regions (LLR = 6.63, p value< 0.05); and in 2016, at east Oromia and northeast Somali regions (LLR = 8.38, p value < 0.05).ConclusionIn this study, though infant mortality has shown remarkable reduction, infant mortality remains a major health care concern and had significant spatial variation across regions. Besides, the study found that infant mortality was highly concentrated in rural areas. Identifying the hotspot areas of infant mortality would help in designing effective interventions to reduce the incidence of infant mortality in these areas. Therefore, the findings highlighted that public health interventions should target rural areas and identified hotspot areas to reduce the incidence of infant mortality.

Rural-Urban Disparities in Pregnancy Intentions, Births, and Abortions Among US Adolescent and Young Women, 1995-2017.

Objectives. To examine rural-suburban-urban disparities in intendedness and resolution of first pregnancies among adolescent and young women (aged 15-19 and 20-24 years) across racial/ethnic backgrounds in the United States.Methods. We used the National Survey of Family Growth and pooled pregnancy files from 2002 through the 2015-2017 surveys. We report baseline rural-suburban-urban disparities in first pregnancy intention and outcomes. We used multinomial logistic regression to estimate these disparities, accounting for sociodemographic background, religious upbringing, and other factors.Results. The first adolescent pregnancies of rural women were more likely to be unintended and end in live birth relative to their urban counterparts. Disparities were most striking among Black adolescents, with about 60% of first adolescent pregnancies among rural Black women being unintended and ending in live birth (urban: 51%). Newly collected state health department data on rural and urban adolescent births and abortions corroborate the findings from the National Survey of Family Growth.Conclusions. Rural-urban differences in the share of first adolescent pregnancies ending in live births are not accounted for by pregnancy intention or confounding individual-level characteristics. Future research should explore the role of structural barriers, including access to family planning and abortion services.

“Our culture, how it is to be us” — Listening to Aboriginal women about on Country urban birthing

BackgroundBirth on Country is often assumed as relevant to Aboriginal women in rural/remote locations and not usually associated with urban environments. In Western Australia, one third of the Aboriginal population live in the greater metropolitan area. We wanted to know Aboriginal women’s experiences of on Country urban births. MethodsIndigenous qualitative data collection and analysis methods were used to learn about Aboriginal women’s stories of contemporary and past experiences of maternity care and cultural practices associated with Birth on Country. ResultsAboriginal Birthing, Senior and Elder women consistently reported ongoing cultural practices associated with childbirth including knowledge sharing across generations and family support, observance of extended family present at the time of or shortly after birth, and how their cultural security was improved when Aboriginal staff were present. Also noted, were the inflexibility of health systems to meet their needs and midwives lack of cultural awareness and understanding of the importance of Aboriginal kinship. ConclusionThe Birthing on Noongar Boodjar project Aboriginal women’s data represents four generations of women’s stories, experiences and expressions of childbearing, which highlighted that maternity care changes across time have failed to acknowledge and support Aboriginal women’s cultural needs during childbearing. In terms of on Country urban birth, the women collectively expressed a strong desire to maintain cultural practices associated with childbirth, including birthing close to home (on Country); having family acknowledged and included throughout the perinatal period; and, having access to Aboriginal midwives, nurses, doctors, and other health care workers to support their cultural security.

A Geospatial Analysis of the Impact of the Baby-Friendly Hospital Initiative on Breastfeeding Initiation in North Carolina.

Significant disparities in breastfeeding support and practice exist in North Carolina. The Baby-Friendly Hospital Initiative is a worldwide intervention that encourages birth facilities to adopt specific practices in support of breastfeeding. This study aimed to evaluate the impact of the Baby-Friendly Hospital Initiative on breastfeeding initiation in North Carolina, with special attention to rural areas. To better understand disparities in breastfeeding initiation across North Carolina, we conducted a secondary analysis of birth certificate data from 2011 to 2014. Univariate and multivariate logistic regression models were used to estimate the association between breastfeeding initiation and (a) birth at a Baby-Friendly hospital and (b) maternal residence in a county with a Baby-Friendly hospital. Model residuals were aggregated by county and analyzed for spatial autocorrelation. Birth at a Baby-Friendly hospital was associated with increased odds of breastfeeding initiation, adjusted odds ratio = 1.7, 95% confidence interval [1.65, 1.89]. Model residuals showed significant clustering by county, with some rural areas' rates systematically overestimated. Whereas presence of a Baby-Friendly hospital in a mother's community of residence was not associated with increased initiation, birth at a Baby-Friendly hospital was associated with smaller disparities in initiation between rural and urban births. Birth at a Baby-Friendly hospital is associated with improved breastfeeding initiation and reduced disparities in initiation between rural and urban counties in North Carolina.

Utilization of Skilled Birth Attendant in Bonga Town, Kafa Zone, South West Ethiopia

Background: Ethiopia with maternal mortality ratio (MMR) of 353 per 100,000 live births, the majority of births are delivered at home and the proportion of deliveries assisted by skilled attendant is very low. Based on EDHS 2014 urban births are six times more likely than rural births to be delivered in a health facility (59% versus 10%). Implementing and assuring utilization of skilled delivery services is potentially one of the most effective maternal health interventions for preventing maternal morbidity and mortality. Objective: To assess utilization of skilled birth attendant (SBA) among mothers who gave birth the last one year prior to the data collection period in Bonga town, Ethiopia. Methodology: Community based cross-sectional study employing quantitative methods was conducted in Bonga town, Kaffa zone, Southwest Ethiopia from June 1 to July 25, 2013. Stratified random sampling technique was employed to select a sample of 296 participants. Logistic regression analysis was performed to obtain predictors of SBA. Results: From the total of 296 deliveries 78.6% of the women utilize skilled birth attendant during delivery. Women’s educational status, their number of pregnancy, Antenatal care (ANC) visit, knowledge about risk factors related to pregnancy and women’s power to make the decision in terms of getting skilled delivery are important predictors for their utilization of skilled birth attendant. Conclusions: Interventional IEC activities focusing on pregnancy complications and benefits of ANC for reproductive age women will be helpful in utilizing skilled delivery attendant so that their influences can be directed in the line of encouraging women to utilize skilled delivery services.

Demography, urbanization and development: Rural push, urban pull and … urban push?

Developing countries have urbanized rapidly since 1950. To explain urbanization, standard models emphasize rural–urban migration, focusing on rural push factors (agricultural modernization and rural poverty) and urban pull factors (industrialization and urban-biased policies). Using new historical data on urban birth and death rates for 7 countries from Industrial Europe (1800–1910) and 35 developing countries (1960–2010), we argue that a non-negligible part of developing countries’ rapid urban growth and urbanization may also be linked to demographic factors, i.e. rapid internal urban population growth, or an urban push. High urban natural increase in today’s developing countries follows from lower urban mortality, relative to Industrial Europe, where higher urban deaths offset urban births. This compounds the effects of migration and displays strong associations with urban congestion, providing additional insight into the phenomenon of urbanization without growth.

Intrauterine exposure to smoking and wheezing in adolescence: the 1993 Pelotas Birth Cohort

Previous studies have suggested an association between maternal smoking during pregnancy and asthma symptoms such as wheezing during childhood. However, few have evaluated this association in adolescence, especially in populations with high prevalence of wheezing as in Brazil. Using the 1993 Pelotas birth cohort, a longitudinal study set in southern Brazil of 5249 urban live births, we aimed to evaluate the association between maternal and the partner's smoking during pregnancy and wheezing at 11 and 15 years of age. We evaluated smoking during pregnancy using number of cigarettes/day, and our main outcomes were as follows: wheezing in the last year and number of wheezing crises, at both 11 and 15 years of age, as well as persistent wheezing (having crises at 11 and 15 years of age) and medical asthma diagnosis at age 15. In addition, other socio-demographic variables were included as possible confounders and mediators of this association. We used Poisson regression models to evaluate crude and adjusted associations. Of the 5249 live births in 1993, 87.5% and 85.7% were followed-up to 11 and 15 years of age, respectively. Maternal smoking during pregnancy showed a dose-response association with number of wheezing crises at age 15 (P = 0.023), presence of persistent wheezing (P = 0.034) and asthma diagnosis (P = 0.023). Partner's smoking was not associated with any wheezing variables. Maternal smoking during pregnancy appears to exert an effect on respiratory morbidity of adolescents, evaluated by wheezing symptoms.

Rural-Urban Differences in Obstetric Care, 2002–2010, and Implications for the Future

Approximately 15% of the 4 million annual US births occur in rural hospitals. To (1) measure differences in obstetric care in rural and urban hospitals, and to (2) examine whether trends over time differ by rural-urban hospital location. This was a retrospective analysis of hospital discharge records for all births in the 2002-2010 Nationwide Inpatient Sample, which constitutes 20% sample of US hospitals (N = 7,188,972 births: 6,316,743 in urban hospitals, 837,772 in rural hospitals). Rates of low-risk cesarean (full-term, singleton, vertex pregnancies; no prior cesarean), vaginal birth after cesarean (VBAC), nonindicated cesarean, and nonindicated labor induction were estimated. In 2010, low-risk cesarean rates in rural and urban hospitals were 15.5% and 16.1%, respectively, and nonindicated cesarean rates were 16.9% and 17.8%, respectively. VBAC rates were 5.0% in rural and 10.0% in urban hospitals in 2010. Between 2002 and 2010, rates of low-risk cesarean and nonindicated cesarean increased, and VBAC rates decreased in both rural and urban hospitals. Nonindicated labor induction was less frequent in rural versus urban hospitals in 2002 [adjusted odds ratio = 0.79 (0.78-0.81)], but increased more rapidly in rural hospitals from 2002 to 2010 [adjusted odds ratio = 1.05 (1.05-1.06)]. In 2010, 16.5% of rural births were induced without indication (12.0% of urban births). From 2002 to 2010, cesarean rates rose and VBAC rates fell in both rural and urban hospitals. Nonindicated labor induction rates rose disproportionately faster in rural versus urban settings. Tailored clinical and policy tools are required to address differences between rural and urban hospitals.

Prospective study of determinants and costs of home births in Mumbai slums

BackgroundAround 86% of births in Mumbai, India, occur in healthcare institutions, but this aggregate figure hides substantial variation and little is known about urban home births. We aimed to explore factors influencing the choice of home delivery, care practices and costs, and to identify characteristics of women, households and the environment which might increase the likelihood of home birth.MethodsAs part of the City Initiative for Newborn Health, we used a key informant surveillance system to identify births prospectively in 48 slum communities in six wards of Mumbai, covering a population of 280 000. Births and outcomes were documented prospectively by local women and mothers were interviewed in detail at six weeks after delivery. We examined the prevalence of home births and their associations with potential determinants using regression models.ResultsWe described 1708 (16%) home deliveries among 10 754 births over two years, 2005-2007. The proportion varied from 6% to 24%, depending on area. The most commonly cited reasons for home birth were custom and lack of time to reach a healthcare facility during labour. Seventy percent of home deliveries were assisted by a traditional birth attendant (dai), and 6% by skilled health personnel. The median cost of a home delivery was US$ 21, of institutional delivery in the public sector US$ 32, and in the private sector US$ 118. In an adjusted multivariable regression model, the odds of home delivery increased with illiteracy, parity, socioeconomic poverty, poorer housing, lack of water supply, population transience, and hazardous location.ConclusionsWe estimate 32 000 annual home births to residents of Mumbai's slums. These are unevenly distributed and cluster with other markers of vulnerability. Since cost does not appear to be a dominant disincentive to institutional delivery, efforts are needed to improve the client experience at public sector institutions. It might also be productive to concentrate on intensive outreach in vulnerable areas by community-based health workers, who could play a greater part in helping women plan their deliveries and making sure that they get help in time.

Urban Living is Not Associated with Better Birth and Infant Outcomes among Inuit and First Nations in Quebec~!2009-11-30~!2010-04-12~!2010-07-06~!

OBJECTIVE: There is limited and inconsistent evidence concerning rural versus urban differences in birth and infant outcomes for Indigenous peoples. We assessed birth and infant outcomes among Inuit, First Nations and French mother tongue groups by rural versus urban residence in Quebec, Canada. STUDY DEIGN: A retrospective birth cohort study of 5,184 First Nations, 2,527 Inuit and 652,940 French mother tongue (the majority reference) births in Quebec, 1991-2000. RESULTS: In general, rural living was associated with slightly less favorable birth outcomes for French mother tongue women, but somewhat better outcomes for Indigenous women. For both Inuit and First Nations, rural births were half as likely to be small-for-gestational-age compared to urban births. Among First Nations, the difference in infant mortality rates comparing urban to rural areas was not statistically significant. Compared to infants of French mother tongue women, Inuit and First Nations infants were much less likely to be small-for-gestational-age in rural areas, while such an "advantage" diminished for First Nations and reversed for Inuit in urban areas. The disparities in infant mortality among First Nations versus French mother tongue births were greater in urban than in rural areas. These patterns of results remained after adjusting for maternal characteristics. CONCLUSION: Living in urban areas was not associated with better birth and infant outcomes for Inuit and First Nations in Quebec despite universal health insurance coverage, strongly indicating a need for improved socioeconomic conditions, perinatal and infant care for Indigenous people living in urban areas.

Determinants of Infant and Young Child Feeding Practices in Nepal: Secondary Data Analysis of Demographic and Health Survey 2006

Childhood undernutrition and mortality are high in Nepal, and therefore interventions on infant and young child feeding practices deserve high priority. To estimate infant and young child feeding indicators and the determinants of selected feeding practices. The sample consisted of 1906 children aged O to 23 months from the Demographic and Health Survey 2006. Selected indicators were examined against a set of variables using univariate and multivariate analyses. Breastfeeding was initiated within the first hour after birth in 35.4% of children, 99.5% were ever breastfed, 98.1% were currently breastfed, and 3.5% were bottle-fed. The rate of exclusive breastfeeding among infants under 6 months of age was 53.1%, and the rate of timely complementary feeding among those 6 to 9 months of age was 74.7%. Mothers who made antenatal clinic visits were at a higher risk for no exclusive breastfeeding than those who made no visits. Mothers who lived in the mountains were more likely to initiate breastfeeding within 1 hour after birth and to introduce complementary feeding at 6 to 9 months of age, but less likely to exclusively breastfeed. Cesarean deliveries were associated with delay in timely initiation of breastfeeding. Higher rates of complementary feeding at 6 to 9 months were also associated with mothers with better education and those above 35 years of age. Risk factors for bottle-feeding included living in urban areas and births attended by trained health personnel. Most breastfeeding indicators in Nepal are below the expected levels to achieve a substantial reduction in child mortality. Breastfeeding promotion strategies should specifically target mothers who have more contact with the health care delivery system, while programs targeting the entire community should be continued.

Predictors of Maternal Depression in the First Year Postpartum: Marital Status and Mediating Role of Relationship Quality

Existing literature has documented the associations between marital status and maternal depression within the first year postpartum. Using data that is representative of urban non-marital births in the United States with a large over-sample of non-marital births, we investigate the association of maternal depression with not only marital status but also relationship quality with the father of the baby. Quality is independently associated with maternal depression after controlling for marital status and other variables that have been documented as risk factors for maternal depression. In addition, relationship quality explains away the associations between marital status and maternal depression. After controlling for relationship quality, single women were no more likely to be depressed compared to married or cohabiting women.

International Perspectives

Humanitarian efforts by a large number of groups have provided care in many developing countries around the world, including southeast Asia. Beginning around 2000, Project Vietnam, a humanitarian organization supported, in part, by California Chapter 4 of the American Academy of Pediatrics, expanded its already established presence within Vietnam to include a focus that specifically addressed efforts to improve neonatal care and reduce mortality in that country. I became a part of this effort and joined the expanding team devoted to this mission. Part of the impetus for this change by the organization was the establishment of goals by the Vietnamese Ministry of Health (MoH) and the leaders of pediatrics within the country. These goals, stimulated by the millennium goals of the World Health Organization, were aimed at improving the care of newborns and developing systems of care to accomplish sustainable results in this important area of health care. Over the past 9 years, much progress has been made and many lessons have been learned in Vietnam. The improvements have led to reductions in mortality and to the expanded availability of higher-quality modern care for increasing numbers of patients. Such advances have come about through the hard work and dedication of individuals and several organizations such as Project Vietnam as well as the partnership with key leaders within the country. Perhaps as important as these tangible improvements is the information learned from successes and failures that may serve as the foundation of an organizational structure or paradigm that can be used to guide similar efforts elsewhere in the world. The following discussion is a compilation of experiences and descriptions of some of the centrally important events in which we have been involved. The models that have grown out of this include important generalizations with utility elsewhere. Although related by a …

Trends in Rural and Urban Deliveries and Vaginal Births: California 1998‐2002

Pregnant women in rural areas may give birth in either rural or urban hospitals. Differences in outcomes between rural and urban hospitals may influence patient decision making. Trends in rural and urban obstetric deliveries and neonatal and maternal mortality in California were compared to inform policy development and patient and provider decision making in rural health care settings. Deliveries in California hospitals identified by the California Department of Health Services, Birth Statistical Master Files for years 1998 through 2002 were analyzed. Three groups of interest were created: rural hospital births to all mothers, urban hospital births to rural mothers, and urban hospital births to urban mothers. Of 2,620,096 births analyzed, less than 4% were at rural hospitals. Neonatal death rates were significantly higher in babies born to rural mothers with no pregnancy complications who delivered a normal weight baby vaginally at an urban hospital compared to urban mothers delivering at an urban hospital (0.2 [CI 0.2-0.4] deaths per 1,000 births versus 0.1 [CI 0.1-0.1]). Logistic regression analysis showed that delivery in a rural hospital was a protective factor compared to urban mothers delivering in an urban hospital, with an odds ratio of 0.8 (CI 0.6-0.9). Maternal death rates were not different. Rural obstetric services in this period showed favorable neonatal and maternal safety profiles. This information should reassure patients considering a rural hospital delivery, and aid policy makers and health care providers striving to ensure access to obstetric services for rural populations.

A fingerprint characteristic associated with the early prenatal environment

Fingerprints and fingertip ridge counts (RCs) have a significant genetic component. However, they also reflect the nongenetic environment of early pregnancy, an important time window for tissue differentiation and organogenesis. Fingerprints are permanently configured before the 20th week of gestation, and each fingertip's RC is related to the growth and regression of its early fetal volar pads. Rostral and caudal aspects of the embryonic limb bud have different relations to somite segments and to morphogen-activator functions. We hypothesized, therefore, that early fetal circumstances would be associated with a contrast in RCs between the thumb (digit 1) and little finger (digit 5). We obtained RCs from the fingerprints of a sample of 658 Dutch adults identified through prenatal and delivery records of Dutch urban births occurring during 1943-1947, an historical era that included months of wartime disruption with a winter famine. We calculated the mean of left- and right-hand RC differences between digits 1 and 5 (Md15). The Md15 fluctuated in relation to the calendar season of the mother's last menstrual period, but only if the gestation occurred outside of the wartime disruption interval. If the gestation occurred during the disruption interval, the Md15 seasonal fluctuation was not evident. This finding suggests that parental environmental factors may influence the fingerprints of the offspring. Fingerprint RC differences observed in postnatal life may be useful in the study of metabolic or anatomic programming related to the early prenatal environment.

Recruiting for a Longitudinal Study of Childrenʼs Environmental Health Using a Household-Based Probability Sampling Approach

TAB1-O-03 The sampling design for the National Children's Study (NCS) calls for a population-based, multistage, clustered household sampling approach (visit our website for more information on the NCS: www.nationalchildrensstudy.gov). The full sample is designed to be representative of both urban and rural births in the United States, 2007 to 2011. While other survey research efforts have used similar designs with success, this would be a novel recruitment strategy for an environmental epidemiologic study of preconception factors and pregnancy outcomes. A comprehensive pilot study is planned for 2006 to 2009 in central North Carolina: BEFirstNC. We will screen a total of approximately 10,000 households from 4 defined geographic areas (2 urban and 2 rural). The areas were chosen to have a broad range of demographic variation with respect to race/ethnicity and income as well as urban/rural housing units. The study will enroll women planning pregnancy and those currently pregnant, with a small number of women enrolled in the hospital after delivery. The BE First NC study visits mimic the visit schedule planned for the first 2 years of the NCS. Frequent home and clinic visits will continue until the child is 18 months of age. Data collection from participants (women, partners, and children) will focus on topics that are likely to yield meaningful results in a small sample of infants (∼400 children). Participant burden associated with study visits, in-person interviews, mail-in forms, biologic specimen collection, environmental sample collection, and clinical tests will be characterized. Frequent qualitative assessments will evaluate the acceptability of the visit schedule and planned data collection methods, including likes and dislikes of study participants regarding each visit, important factors in the participant's decision making process to join the study, continue to participate or drop out. Spatial environmental monitoring data and community resource information (parks, etc.) will be combined with individual family data to assess the neighborhood as well as household environment. This pilot study can provide valuable information on the feasibility of using a household-based sampling approach to identify, enroll, and retain women and families for a longitudinal study of child health and development. Demographic differences in participant response and retention will be informative for the national study as well as the qualitative assessment of study acceptability. Using a population-based sampling frame for a study of pregnancy outcomes can avoid biases associated with recruiting volunteers who may be more health conscious than nonparticipants and/or may be more concerned about their environment. Measuring aspects of the environment before a couple becomes pregnant allows for an interesting opportunity to assess peri-conceptional factors that may relate to pregnancy outcomes as well as child development. This is an abstract of a proposed presentation and does not necessarily represent Environmental Agency policy.

The challenge of reducing neonatal mortality in middle-income countries: findings from three Brazilian birth cohorts in 1982, 1993, and 2004

Middle-income countries will need to drastically reduce neonatal deaths to achieve the Millennium Development Goal for child survival. The evolution of antenatal and perinatal care indicators in the Brazilian city of Pelotas from 1982 to 2004 provides a useful case study of potential challenges. We prospectively studied three birth cohorts representing all urban births in 1982, 1993, and from January to July, 2004. The same methods were used in all three studies. Despite improvements in maternal characteristics, prevalence of preterm births increased from 6.3% (294 of 4665) in 1982 to 16.2% (342 of 2112) in 2004, corresponding to a 47 g reduction in mean birthweight. Average number of antenatal visits in 2004 was 8.3 per woman, but quality of care was still inadequate--97% of women had an ultrasound scan, but only 1830 (77%) had a vaginal examination and 559 of 1748 non-immunised women did not receive tetanus toxoid. Rate of caesarean sections increased greatly, from 28% (1632 of 5914) in 1982 to 43% (1039 of 2403) in 2004, reaching 374 of 456 (82%) of all private deliveries in 2004. The increased rate of preterm births seemed to result largely from caesarean sections or inductions. Newborn care improved, and gestational-age-specific mortality rates had fallen by about 50% since 1982. As a result, neonatal mortality rates had been stable since 1990, despite the increase in preterm deliveries. Excessive medicalisation--including labour induction, caesarean sections, and inaccurate ultrasound scans--led by an unregulated private sector with spill-over effects to the public sector, might offset the gains resulting from improved maternal health and newborn survival. These challenges will have to be faced by middle-income countries striving to achieve the child survival Millennium Development Goal.